ISRAEL: Rabbi's little helper

Written by Yair Ettinger

Forget 'Big Brother': Psychiatric drugs are frequently administered within the Haredi community at leaders' requests, in order to bring members in line with norms, say sources.

Psychiatric drugs are rife in Israel's ultra-Orthodox community, sources say,

This is not a reality show. It's a true story that's been going on for years. No one denies it, neither the psychiatrists nor their patients: Psychiatric drugs are being given to ultra-Orthodox yeshiva students, men, seminary girls and married women at the request of rabbis, yeshiva "supervisors" and marriage counselors. The furor that erupted recently after a psychiatrist prescribed pills to participants on the TV reality show "Big Brother" - apparently to help the production and not the patients - convinced some Haredi patients to come forward with prescriptions and documents attesting to a far broader practice.

Haaretz spoke to psychiatrists and others knowledgeable about psychiatric treatment in the Haredi community, and collected testimonies from half-a-dozen patients and their families. About half of them are Haredi and the others have left the community. Each told a different story, mentioning the names of senior psychiatrists, rabbis and community functionaries.

Last December, the Israel Psychiatric Association held a symposium titled "The Haredi Community as a Consumer of Mental-Health Services." Deputy Health Minister Yaakov Litzman, a Gur Hasid, was invited to speak, as were several psychiatrists who treat Haredi patients and well-known Haredi medical go-betweens (i.e., people who help mediate between patients and professional ).

Conference organizers included Prof. Omer Bonne, director of the psychiatry department at Hadassah University Hospital in Ein Karem, Jerusalem, who gave a talk about "Culture-dependent psychiatry in the Haredi community." Bonne, a highly esteemed veteran physician, praised that population's growing openness vis-a-vis the field, but made a few comments that caused some audience members to shift uneasily in their seats. For example, Bonne said that sometimes yeshiva students and married men should be given antidepressants even if they do not suffer from depression, because these drugs also suppress sex drive.

"Some behaviors put Haredim in conflict with their values and cause them mental problems, even to the point of depression," Bonne said. "My view concerning drug treatment in such cases has changed. For example, when I was young, idealistic and less experienced, whenever I had a case of homosexuality, masturbation - or, as Haredim put it, 'compulsiveness in sex' - I would say: 'Homosexuality is not a mental problem, masturbation is certainly not a mental problem or even a medical problem. I do not treat people who do not have a medical problem.'

"Over the years, I saw that people who do these 'awful' things suffer terribly because of the conflicts they create. Those urges, impulses or behaviors place them in conflict with their society, and then they become depressed. In these cases, I would indeed prescribe medicines that block these conditions."

The implication would seem to be that Prof. Bonne wants to prevent patients from experiencing mental conflict. In practice, treating such cases ostensibly puts the patients back on the straight and narrow, in keeping with the interests of rabbis (who are often the ones pushing for psychiatric treatment ). Bonne acknowledges that this may be an exceptional approach, but others agree with it, too. "Currently, their society has no good solution for this," he says, referring to homosexual urges. His remarks suggest that prescription drugs are often the only way out.

Dual loyalties

Psychiatrists who treat yeshiva students are almost always consulted privately, as opposed to via the public health system. In certain cases the treatment is paid for by a rabbi, mashgiah (a supervisor who oversees educational and spiritual levels among students), or medical go-between. Psychiatrists interviewed for this article say the connections between the Haredi establishment and psychiatrists raise ethical questions, at the very least. As the Israel Medical Association states: "The physician shall safeguard the patient's privacy and medical confidentiality," and "he shall not take part in any action that compromises [the patient's] physical or mental integrity or human dignity."

One psychiatrist raises the possibility that his colleagues "could become emissaries of the Haredi establishment." Yet another noted that the "pressure" from Haredi rabbis and functionaries leads some of his colleagues to develop "dual loyalty" - instead of remaining loyal to the patient alone, they see an opportunity to increase their patient load.

Psychiatrists say there are welcome trends as well: greater awareness and readiness to treat mental distress despite the stigmas (which exist among society at large ) and the possible adverse effect on matchmaking. This is partially due to advice columns on psychological problems within the Haredi media. One such column, which has run for years in the women's supplement of the veteran newspaper Hamodia, often encourages psychiatric drug use.

But psychiatric treatment is proliferating above all due to personal, discreet recommendations by rabbis, functionaries and yeshiva supervisors, or even by well-known leaders such as the Gerer Rebbe and the Amshinover Rebbe. They are thought to possess "understanding" of the psyche and they recommend psychiatrists whom they trust to people who come to consult with them about psychological problems.

Some seeking help have to pay for the treatment themselves. Others, though, get funding, and may not always know who is paying.

Years ago, the Ger Hasidic dynasty established a fund called Saving the Generations (Keren Hatzalat Dorot ) in order to help Hasidim offset fertility treatment costs. Over the years, the fund, which was created by Rabbi Yosef Kuperberg, a confidant of the Gerer Rebbe (Kuperberg is now also the chairman of the Agudat Israel Central Committee ), increasingly began helping Hasidim treat mental problems.

The fund periodically calls for donations, via mail or through Hamodia. One such letter stated that the fund engages in "finding relief and cures for mental health problems and distress." The letter, which Haaretz saw at the time, added, "Nowadays extremely complicated problems can be solved via proper treatment. The fund's officials are in close touch with senior physicians and well-known professors. Based on their precise diagnosis, suitable medicines are administered as needed, producing no side effects, so that one can return to a healthy, happy daily life. Medicines and treatments in this painful sphere are extremely expensive, and the fund covers them for those who cannot afford them."

The Ger (or Gur ) sect, Israel's largest Hasidic group, with tens of thousands of followers in communities from the Galilee to the Negev, is exceptional even within the Haredi world for its conservatism, particularly regarding sexuality. The current Gerer Rebbe, Yaakov Aryeh Alter, is known to ascribe importance to health matters, including mental health. It was under his leadership that the community developed systems for addressing this issue. Hasidim say drug treatment has been widespread within high-school yeshivas for years.

"The fool is worse than the wicked," says a married yeshiva student, referring to the founders of the Saving the Generations. The rebbe's emissaries often truly wish to help, "but because of their stupidity they trample souls upon souls, and I ask myself how aware they are of this," he says.

Haim (not his real name ) was a member of the Ger community for his first 23 years. Over that time, he was repeatedly treated by psychiatrists and prescribed medications. Three years ago, he divorced his wife and abandoned religion.

"Sometimes they [the supervisors or the teachers] want to help, but they don't know anything about psychology. Someone brought up the idea of medication, and it caught on like a gimmick. They love gimmicks."

A department head at a Jerusalem area psychiatric hospital that treats many Haredim says he's seen "normative youths at a small [high-school] yeshiva who have no disciplinary problems but were having difficulty with Gemara studies. Some psychiatrists have no problem prescribing Ritalin for them, often at the rabbis' request. This shocks me. The psychiatrist is becoming the ally of the rabbis instead of the patients. No one even considers that perhaps the kid is unsuited to study Gemara all day.

"Some boys are sent for medical treatment because they were caught doing something in the shower," he says, referring to physicians in general, not necessarily those mentioned in the article. "There is often no justification for this."

Another well-known psychiatrist said he used to get many calls from Haredi functionaries, but that they dropped off when he resisted what he called rabbis' "pressure" to prescribe particular drugs to Haredi youth and married men. "Perhaps they found other psychiatrists who prescribe medicines without asking too many questions," he says, adding that he takes a grave view of such behavior.

"The issue also exists in the army, where in many cases the expectation is that the physician will declare the patient healthy. Here, we sometimes find the opposite: over-diagnosis. If you say a person aspires to maintain a particular way of life, based on specific values, then you do what you can, including via medicine, to allow him to live up to those values. There is a problem on the part of psychiatrists, who are legally and ethically committed to help patients but in some cases become delegates of the Haredi establishment and their values. And this goes far beyond a handful of participants in 'Big Brother.'"

The "Big Brother" outcry centers around the allegation that a psychiatrist prescribed medication in keeping with the needs of the production staff, but not necessarily those of the patient. Dr. Ilan Rabinovich, the psychiatrist employed by the program, denies this categorically. In some cases, Israel's top clinics are sometimes mobilized to the Haredi cause, knowingly or unknowingly, via yeshiva heads who are thought to know something about psychiatry, community therapists and various go-betweens with no official position.

Prof. Bonne confirms that go-betweens, rather than the patients, are often the ones who contact the psychiatrist, and they also accompany the treatment process. "It's rare for educators [in other communities] to be so involved. Overall, I think this is positive, since these are people they trust. ... In most cases I think that the therapists, the rabbis, the teachers and the supervisors truly want what is best for the patient, and genuinely believe he is better off conforming with the system. But this is not always the case, and I do not prescribe medicine to everyone. It's not automatic."

False diagnosis

Haya (not her real name ), also a former member of the Ger community, left her family and religion by means of a bumpy road that included a psychiatric referral as soon as she sought to divorce her husband a few years ago. "The day I launched divorce proceedings in the Family Court, I was threatened that if I did not drop them by noon the following day, I would lose my children," she recalls.

"My father went to court with me to ensure I was dropping the case," she continues. "He told me he had something important to tell me, that he had been hiding something from me for months - that I was manic-depressive. My father played a major role in my life, and if he said so, I thought he must be right.

"I went to see a well-known psychiatrist in the center of the country. [Haya requested that his name not be published.] I believed he would save my life. I don't wish those feelings of helplessness on anyone. When I arrived, I saw a Hasidic man who apparently was paying my bill. It all became very fishy at that point. Maybe psychiatrists are also a type of victim: the go-betweens lie to them freely. I don't blame the psychiatrist, but the functionaries. They are the ones who control everyone."

Haya says she met with the psychiatrist once.

"He wrote 'needs follow-up.' After my divorce, I found an amazing female psychiatrist who saved my life. It took her half a year to persuade me I wasn't manic-depressive. That was critical. I'd thought that if I was mentally ill, I could not take responsibility for the children. I had to fight for my sanity and find psychiatrists who would help me. I am a strong person, but I wonder what happens to more vulnerable, less knowledgeable women."

A senior psychiatrist who treats Haredim told Haaretz that some who take up a secular lifestyle overnight might be suffering from a manic condition.

"In these cases, people make decisions that are not level-headed, give in to their impulses and pursue an unrealistic image of the secular world. They think that if they become secular they will have intercourse with everything that moves. I prescribe lithium for people who are manic. In most cases it helps, and afterward they tell me, 'I lost my judgment.' If they are not manic and they really thought it through before becoming secular, the pill won't change that. The pill won't change your worldview."

Haim, who was raised in a Ger community in the north, says, "Some guys are full of pills. My little brother was given Ritalin from age 13 or maybe even earlier. My father didn't want to tell him what it was, so it wouldn't hurt his marriage prospects. Plus, since I hadn't wanted to take pills, he decided to trick my brother by telling him they were vitamins. My father has no schooling at all, but he and the teacher at the heder determined the diagnosis and gave him pills. They were provided by the family doctor, who probably would have given my little brother Prozac or oral contraceptives had my father asked."

Haim, now 26, is secular and independent, and maintains only loose ties with his family. He was given medications for nine years, beginning at age 14, even though he says it was never forced on him, unlike the cases of other people. He now believes he never needed the medicines, other than Ritalin for ADHD. The treatment was initiated by rabbis, yeshiva supervisors and his marriage counselor in Ashdod, who worked with him during his two years of married life.

Haim showed Haaretz documents and prescriptions revealing that he was treated by Dr. Ilan Rabinovich and by Profs. Omer Bonne and Avi Weizman.

"I have had learning disorders and hyperactivity from infancy," he says. "When I was about 14, the yeshiva counselor told me, 'Let's do non-spiritual treatments, let's start seeing professionals.' That's how it started. The school supervisor got into drug treatment and really went for it. Within a year there were rumors that one out of every three students at the yeshiva was taking Ritalin or Prozac. Some of the students, like me, requested an professional medical opinion. He would send us to a psychiatrist, who would provide a diagnosis, paid for by the children's parents.

"I know some students received hints that they would be thrown out of the yeshiva if they didn't take the pills. That is a very extreme measure. Unless you have sex at age 13, you won't be thrown out of a yeshiva. Maybe one person a year is thrown out. In this case they went full-force. Parents were pressured, too: The rabbi would call, the parents were persuaded. A few students, including me, threw the pills down the toilet. I was prescribed Ritalin, some of the others got Prozac. The overseer administered the Prozac personally."

Why Prozac? Did they have depression?

"How does depression manifest itself in a Haredi yeshiva? It's different there. Depression is everything that interferes with functioning. You don't wake up for prayers, say, and the supervisor asks you why you didn't get up - 'Maybe you should be thrown out of the yeshiva because you aren't religious enough?' The guy says he is religious but can't get up. So the supervisor realizes it's something mental, and the only things he knows are depression and attention deficit disorder."

Was Prozac given to students with sexual "problems," including homosexuality or masturbation?

"That is a constant rumor in the yeshivas - that students are being given pills that work like chemical castration. But I never encountered that."

Sexual suppressant

At the psychiatrists' symposium, Prof. Bonne said explicitly that yeshiva students are prescribed SSRI-group antidepressants, including Prozac, Lustral, Cipralex and Seroxat, due to their sexual side effects: reducing urges and slowing ejaculation.

Bonne says antidepressants are used to avoid destructive conflicts that would make students depressed.

What is the purpose of the pharmacological treatment? Are you seeing to prevent a destructive conflict?

"To prevent depression," says Bonne.

Wouldn't it be better to advise the teen to leave the place causing him suffering? Maybe to stop being Haredi?

"I don't say, 'The Haredi system is problematic because it places people in conflicts that lead to depression.' Theoretically, I could say, 'Look what this system is doing.' I don't do that. I give people the information, and if they choose the path then I will prescribe them medicine."

Have you found this really helps people spare themselves the conflict?

"It does much more than that. It enables them to preserve their place, image and dignity within the system, to continue to maintain proper family and social relations, and to find a match and raise a family."

Haim says that after he was married, he asked his marriage counselor to set up a meeting with a psychiatrist.

"At the age of 21 I got into a certain conflict , and I wanted to suppress my sexual urge. After a year of marriage, when we were living in Ashdod, I got into a complicated conflict."

Haim approached Kuperberg, who referred him to Prof. Avi Weizman.

"Weizman conducted a professional diagnosis," Haim says. "He gave me pills to relax, not to suppress sexual instincts. ... I saw him three times. I found out that Ger sends people to Weizman. His waiting room is packed with Ger Hasidim."

Haim took antidepressants and anti-anxiety medication for the two years he was married. His wife received medication to treat compulsive disorders. "My wife didn't know I was taking pills, but I knew she was taking them. That's how it is in Ger. You don't tell."

Haim later visited Dr. Rabinovich. "My cousin took me. . My cousin didn't come because he was my cousin, but because he was trying to promote himself within the psychiatry sphere. I saw Rabinovich with the go-between and Rabinovich gave the prescription and the forms to him, not me. I was sitting with him in the room, and he asked Rabinovich for the forms and was handed them.

"Rabinovich doesn't have the sensitivity to understand that I was Haredi," he continues. "I can't tell someone to leave. You don't do that. Haredim don't do that. Rabinovich might think I trust my cousin, but I don't. I would not want him to be involved, but he set up the appointment and he paid. I was dependent on him."

Haim adds, "Rabinovich made a professional diagnosis and wrote things. He wrote more or less the same as Weizman - anxiety, depression - and prescribed pills. So I take them in loads, because I want to solve my personal problems."

Haim's last psychiatric treatment was with Prof. Bonne, whom he visited with a senior Hasidic functionary from outside the Gur community. That person treated his ex-wife and gave her a steady supply of medicine, and he was the one who initiated the appointment with Bonne, says Haim.

"Through my wife, he suggested that I go to Dr. Bonne. He said he would come with me to Jerusalem. I respected him, because since he started treating my wife, I believed he would fix all my troubles. I met with the functionary and we took a taxi to Rehavia, Jerusalem. I didn't want him with me during the appointment, but he sat down in the room. After talking to him for a few minutes, the psychiatrist tells me, 'Wait outside, I want to exchange a few words with him,'" recalls Haim.

"When I came back in, Bonne asked me questions: How I define myself in religious terms, whether I consider myself religiously deviant. The functionary heard it all. I don't remember what I told him, but I wanted to get treatment, so I expressed my feelings more or less. Two weeks later, while I was at synagogue, [my wife's] parents came to our home and took her. They called me and said, 'We packed up and took our little girl. We want a divorce.' Just like that."

Haim feels that the meetings with Bonne and the functionary contributed to his divorce.

Bonne says he makes a point of receiving the patient's permission to have someone else present in the room.

Haim, what do you think is wrong here?

"They control you: how many children you have and when you sleep with your wife. They bring you to a psychiatrist and listen to the opinions. They are deeply ingrained in your personality, they hear what you tell the professional. They are involved in the process between you and the psychologist or the psychiatrist. They penetrate your psyche. We forgave them for telling us how to behave in the synagogue, or even at home. Here they're entering your inner self."

Where did it take you?

"I complained about heightened sex drive. In the Gur community it is strictly prohibited to enjoy sex, and my conscience was in overdrive because of my desire for sex. You have sexual relations with your wife only twice a month. I felt guilty because I wanted more. I wanted to suppress that. They used it against me. I wanted to improve myself and I asked the system for help, and in turn it hurt my family. After that I stopped taking pills, divorced, moved and abandoned religion. Now everything is fine. I am not taking anything and I am doing well."

Schizophrenia pills for a better life

As opposed to Haim, Yaakov (not his real name ) decided to stay in the Ger community. He is unwilling to say why he was sent to Dr. Rabinovich.

"I am a normal person, very much so," he says. "I was sent to Ilan Rabinovich two and a half years ago because of a very specific story.

"I was sent by a spiritual counselor, a well-known person in the Hasidic world. I sat with Rabinovich and [the counselor] started to charm him, and in the end he prescribed pills. 'This will make your life better,' he told me.

"I never touched them. I went home, and since I'm a slightly rebellious Haredi with Internet access I looked on Google and read all I could about Ilan Rabinovich. I saw forums where patients wrote good or bad things about him. I saw the pills he gave me were intended to treat schizophrenia. I'd heard stories about Hasidim who had taken those kinds of pills, which destroyed their nervous system.

"When the rabbis and functionaries realized that I did not intend to take the pills, they declared me persona non grata. They didn't throw me out, but the institutions broke off all contact with me," he says.

"Secular people like to criticize Haredim over two issues: draft evasion and not working. I don't think these two issues justify hatred. The true story of the Haredi community is the trampling of human and property rights. It's incredibly suffocating. Some of the people handing out pills in our community are true saints; most have good intentions and want to help. To really understand what's going on here, you have to know how the good is mixed with the bad, with the darkest things."

Countering stigmas

Rabbi Yosef Kuperberg, who founded Saving the Generations to help Haredim pay for fertility treatment and later mental health care, refused to respond to Haaretz, but an anonymous source at the foundation presented the rabbi’s views on psychiatric treatment. It’s crucial that someone accompany Haredi patients to meetings with psychiatrists due to cultural gaps: For many yeshiva students, this is their first time meeting someone outside the Haredi world, says the source.

“People may accompany the patient, who often is embarrassed to express himself,” says the source. “So people help him. The escorts should be praised. Wouldn’t you want someone to help you express yourself in an unpleasant situation?”

He adds, “We consistently encourage a person not to seek help alone, and we do not encourage parents to get involved. Generally patients exaggerate or underestimate an issue − it’s not that they’re lying; they’re distorting the picture. So it’s good when somebody more objective comes along. The doctor has no objective measure; you can’t make a [definitive] diagnosis in these cases. Assessments are made based on a story. So the truth needs to be heard.”

One of the foundation’s main purposes is to improve awareness of mental health services, and to counter the stigmas surrounding them, he says.

“There is a deeply embedded reluctance to psychiatric care,” says the source. “You can find aspirin in any home, but rarely Valium − why? The stigma calls Valium the ‘deputy’ of the angel of death. People may face pain much more severe than a headache or a toothache. The damage caused by not taking aspirin is negligible compared to the damage caused by stress.”

Are pills given to reduce sexual urges?

“The medical profession has answers to minor, moderate and very severe problems. There are solutions for those who suffer from urges and do not behave as they would like to behave.”

Are teens told the nature of the drugs they’re being given?

“Since the stigma against Valium is so strong, and it is even worse regarding more serious medications, instead of being helped by it, [Orthodox] youths curse it, denounce it.”

Do Ger Hasidim more frequently turn to psychiatrists? If so, why?

“To some degree, yes. It could be that the Gur leaders are a little more open, that they have broader vision, and that they want to help their people. That’s all there is to it. Opposition [to professional care] will erode: It could take two years, or five or 10 years, but in the end, we hope that anyone feeling abnormal stress, if he’s half-crazy, if he’s hitting people or if he is compulsive will seek help, just like people take aspirin for a headache. Compulsiveness is normal, but when it becomes harmful, why should a person suffer?”

Who funds psychiatric care for Hasidim who need it?

“Usually the families − who else? Saving the Generations helps people who can’t pay, but does not provide regular funding.”

Doctors respond

“Many patients, ultra-Orthodox and secular, come to me with a companion,” says Prof. Omer Bonne. “Sometimes it’s a family member, sometimes it’s someone else the patient trusts. At the start of each session I ask the patient whether he or she wants the other person to be present, and I always respect the patient’s decision. I’ve never forced a patient to have someone else in the room during an examination.

“Cultural norms are very important when diagnosing mental illness. The person mentioned in this article [the non-Gur functionary in Haim’s story], like other Haredi activists and family members, helps me come up with an initial assessment and then a diagnosis. He says he arranged the meeting and knew the family well, so I may have asked him − with Haim’s knowledge − for information.

“Haim claims his decision to see me was initiated by that person, that he considered him a ‘savior.’ Did [Haim] take a cab from Ashdod to Jerusalem with him in order to come to the appointment alone? Did he intend to use his help for free? And if he really wanted to be examined alone, why didn’t he say that? I have never passed on medical information about a patient without his or her explicit consent ‏(aside from situations stipulated by the law‏), in this case or any other.”

Moshe Klughaft, Dr. Ilan Rabinovich’s media consultant, states: “Dr. Ilan Rabinovich, a leading psychiatrist who upholds the highest standards of care and runs Israel’s leading private psychiatric clinic, improves the quality of life of thousands of people a year. Dr. Rabinovich is proud of his work over the years with [Gerrer Rebbe confidant] Rabbi [Yosef] Kuperberg and other rabbis. These are top-caliber people who work day and night to help the public. Dr. Rabinovich has spearheaded a revolution over the past decade, not just among the secular but also among the ultra-Orthodox: He has helped do away with stigmas, stereotypes and fears about psychological and psychiatric care, and about how such treatment can profoundly change a patient’s life.

“The ultra-Orthodox are not treated differently than the secular. Dr. Rabinovich provides both communities with top-quality treatment, as if treating his own children. Since his work relates to mental health, Dr. Rabinovich will not disclose information about specific patients or their treatment. Dr. Rabinovich refuses to exploit patients’ mental health in order to get his name into the newspaper.”

Prof. Avi Weizman says he is usually contacted initially by patients’ parents. “They direct the course of events, and they come to me,” he says. He also confirms that many of his patients come escorted by a rabbi or a yeshiva supervisor. “I make sure that the escorts remain outside, unless the yeshiva student says, ‘I want the supervisor to sit with us.’”

Weizman denies prescribing medication to curb sexual impulses, “unless there is something compulsive. It is normal for people to masturbate, and I would never prescribe a drug for that.” The patient’s family usually pays for the treatment, he says.

“In 99 percent of the cases, the parents come with the child. All contacts are initiated by the parents. If nothing is needed, I do not provide treatment, but I do address situations where I feel the quality of life can be improved, suffering can be mitigated and feelings of failure can be countered,” he says. ‏

http://www.haaretz.com/weekend/week-s-end/rabbi-s-little-helper-1.422985