‘Mr. A” is a 43-year-old chasidic man who is so afraid to make mistakes in his daily prayers that he cannot bring himself to get out of bed until noon or 1 p.m. The reason? Obsessions he’s faced since his days in yeshiva, when he was consistently the last person to finish praying each morning.
“He thought he was just more religious than everyone in the class,” said Dr. Steven Friedman, a professor of clinical psychiatry at SUNY Downstate, who was addressing a group of fellow therapists. “Patients who have religious obsessions often don’t recognize or admit that they have symptoms.”
Friedman was speaking to a group of 30 therapists — at least 20 of them Orthodox Jews — who had gathered for a three-day conference this week at SUNY Downstate Medical Center in Brooklyn sponsored by the Behavior Therapy Training Institute of the International Obsessive Compulsive Disorder Foundation. While the Institute holds about three of these meetings annually, this was the first conference tailored specifically to the needs of Orthodox Jewish therapists, who had been unable to attend regular Saturday programming.
Sessions last weekend were largely the same as any other Behavior Therapy Training curriculum, aside from Friedman’s Sunday afternoon lecture about “Religious Scrupulosity,” which targeted obsessions and compulsions rooted in Jewish ritual. In addition to discussing these specific behaviors and treatment techniques, the doctors focused on the unwillingness of many Orthodox Jews to even seek treatment, in a community where mental health issues are somewhat taboo.
“You can speak Yiddish like I do and you’ll still find that that won’t get you access to certain populations,” Friedman said. “Since the community is so small, most of them you know and it’s one degree of separation. If you give me the name of an Orthodox person in the United States, I can find someone who knows something all about them.”
“This is problematic when you do therapy,” he added.
OCD is a genetic disorder that equally affects men, women and children of all backgrounds, typically appearing between the ages of 10 to 12 or in late adolescence or early adulthood, according to the Foundation. On average, OCD inflicts 1 in 100 adults and 1 in 200 kids and teens, amounting to about 2 to 3 million adult cases and 500,000 childhood cases in the United States alone. Because OCD runs in families, there is a 15 percent chance that a patient’s child will also exhibit OCD, though not necessarily in exactly the same form, Friedman explained. For example, he said, a parent might be an incessant hand-washer, while the child might become a compulsive checker.
Be it contamination, relationships or religion, OCD “always attacks what’s most important,” according to Friedman, and for Orthodox Jews with OCD what’s most important is their daily commitment to Judaism. And so much of Orthodox Judaism — or anything religion — is about prescribed ritual, like the particular order in which Jews put on and tie their shoes, adjust tefillin precisely on their heads or clean themselves before prayer.
Ironically, however, OCD patients may get so much anxiety from the religious practices that they don’t even enjoy the rituals and beliefs that are so important to them. Prayers and religious behaviors will often be painful processes, punctuated by incessant questioning and reassurance seeking from rabbis and elders.
“You see a lot of compulsive behaviors with the intention of undoing something that has been done wrong,” said Dr. Jeff Szymanski, the executive director of the International OCD Foundation. “I have to repeat it until it’s done perfectly.”
Friedman added, “People with OCD don’t really get any joy out of their religious experience.”
Instead, they may spend inordinate amounts of time doubting and checking — whether they prayed correctly, whether they greeted every single person in shul, whether they scrubbed their hands for long enough between handling milk and meat. One patient was so worried about clearing his house of chametz during Passover that he built his own extremely dangerous — not to mention illegal — matzah-baking oven in his basement. Intrusive thoughts may also extend to aggressive and sexual obsessions, such as momentarily perceiving the rabbi as a Nazi, thinking the Second Temple was for pagans or fearing homosexuality when one is not actually gay.
“A lot of Orthodox Jewish men seem to have this fear. It’s not usually true. I usually just ask them one question, are you attracted to men?” Friedman said. “And the answer is usually no.”
For Orthodox women, he says, the most problematic Jewish rituals for patients are properly adhering to kashrut and observing “family purity” laws, which Friedman calls a “torture” for some OCD patients, particularly due to the meticulous checking and counting required of them each month.
“The rituals will typically be offshoots of their current religious practices. Their faith-based practices will get co-opted by the OCD, so [a Jewish patient’s] compulsive behavior will look a bit different from someone who is Protestant or Muslim,” Szymanski said. “But the themes are pretty consistent — it’s typically a fear of offending God or engaging in something blasphemous, a fear of hell, of Satan, of doing something imperfectly. The compulsive behaviors are typically things like praying a certain way and praying enough.”
Among patients of other religions, Friedman found one Hindu man who was so afraid of stepping on God that he wouldn’t get out of bed, as well as many Muslims who were so concerned with performing absolutions (washing) properly that they were unable to begin prayers. For Catholics, imagining Jesus sleeping with the Virgin Mary is a popular obsessive fear.
The best way to conquer — or at least subdue — obsessions and compulsions is to undergo cognitive behavioral therapy with exposure to the trigger, a technique that is all too often left out of medical school and doctorate curricula, according to Szymanski. At their triennial conferences, the OCD Foundation aims to compensate for this oversight and teach therapists the newest techniques in cognitive behavioral therapy. For any patient with moderate to severe levels of OCD, Friedman adds that an on-site home visit is also crucial when assessing behavioral patterns.
“I actually go to the bathroom with them and say, ‘Show me how you wash,’” he said. “People are not in touch with many of their compulsions.”
And he believes that for the most part, Orthodox patients will progress better with Orthodox therapists, despite the fear that they may have some of the same friends and acquaintances in their close-knit communities.
“Ultimately for OCD and [religious manifestations of it], probably most of our patients are better served by seeing someone within the community who knows the intricacies,” Friedman said, noting that he’ll often help people by labeling their obsessions in Jewish terms — “mishegas” (craziness) for adults and “nudniks” for kids.