Witztum and Buchbinder article (117-124) explores strategic culture-sensitive therapy as an effective approach when dealing with cases that exhibit client-therapist differences in all religious and cultural backgrounds.
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The fundamentals of traditional and modern approaches of treatment are the myth and rationale models. These models explain the treatment process, including health, illness, deviance and normalcy.
When therapists and patients belong to different cultural, ethnic or religious groups, conflicts may arise. This necessitates therapists to abandon their disbelief regarding the patients’ perceptions and learn their culture, including their treatment explanatory models and worldviews.
Based on three sample cases of therapy with the ultra-orthodox Jews, the two authors create a strategic and integrative cultural-sensitive model of treatment.
The Ultra-Orthodox Living in Israel
The Ultra-Orthodox people living in Israel are fundamentalists. Therefore, they face the challenge of coping with secularization and modernization. Besides, they comprise of various streams with differing worldviews, religious priorities and social structures, thus lacking homogeneity.
These differences may seem insignificant to the wider public but they have the potential of generating tension among the streams. Moreover, the traditional Jewish law fully informs their way of life.
As a result, they unify to reject secular life approaches by living in secluded and self-sufficient communities.
Mental Health Services Among the Ultra-Orthodox
The ultra-orthodox seek psychiatric help as their last option due to religious concerns, such as using drugs during fasting. In most cases, they prefer consulting the rabbis. Unfortunately, most classical rabbis perceive God as the ultimate healer and discourage doctor’s help.
Besides, they associate mental health problems with stigma, prejudice and immorality. This makes medical intervention irrelevant.
More so, therapists use scientific and rationalistic approaches which some ultra-orthodox perceive as anti-religious, thus frustrating their efforts when seeking treatment. However, the new generation of informed rabbinic leaders is encouraging the American Jews to seek medical help.
The rabbinic leaders are neutralizing the tension that exists by perceiving doctors as God’s messengers.
Cultural Influences on Idioms of Distress and Narrative Construction
Idioms of distress are the culturally unexpected ways through which people express distress and cope with pain. For example, after marriage, some cultures take wives to their husbands’ homesteads where they are isolated.
This stresses the newly married women because they cannot communicate with their families. In some cases, culture does not allow them to express their distress openly. As a result, they express their distress in culturally unexpected ways, such as having irregular menstrual periods.
Idioms of distress may differ across cultures because different cultures express distress through different ways. Ideally, cultures may express stress through cognitive, emotional, behavioral, interpersonal and experiential symptoms.
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This depends on how factors, such as history and physiology determine the acceptable distress idioms of a culture.
Idioms of distress in the ultra-orthodox society
Religion and overtone strongly influence the idioms of distress exhibited by the ultra-orthodox. Some of the ultra-orthodox idioms of distress include compulsive rituals, depression, delusions and obsessive thoughts.
These idioms involve religious content, practices and symbols, including purity and prayers. For instance, patients with depression report self-criticism and guilt associated with religious practices. Those with psychosis experience delusions associated with Jewish mysticism.
This informs that culture-sensitive therapy should consider the religious association of idioms expressed by the ultra-orthodox.
Working With The Ultra-Orthodox
The ultra-orthodox therapist-client conflict is more intense because the focus is on moral ideological foundations. The ultra-orthodox Jews are not ready to integrate with the “others.”
They separate themselves religiously and geographically by creating ultra-orthodox communities and avoiding any interaction with secular persons. Hence, according to them, the therapists are impure and secular.
Based on this, a therapeutic dialogue should commence with a religious framework that provides patients with the platform to express their distress. Interventions that interweave ultra-orthodox cultural aspects should follow to help therapists nurture cooperation and trust.
The Treatment Situation
Difficulties in treatment arise due to conflicting therapist-patient symbolic realities and models that explain illnesses. This creates the challenge of ensuring that religion and medicine do not contradict.
This could be achieved by employing professionals from the same ethnic group to lessen symbolic reality. To minimize contradictions, secular therapists should learn about patients’ culture to create an emotional connection with patients.
They should transform cultural knowledge into practical interventions. They should also know how to use the “ritual language.” This helps in isolating metaphoric idioms and expressions.
In addition, therapists should acknowledge that counter-transferential and transferential reactions develop during therapy. Having enough cultural knowledge will help reduce the reactions by reducing distorted stereotypical thinking.
Case 1— If I can’t pray, what’s the point of living?
This case involves a 35-year-old man who is a devout religious observance for 10 years. Allan becomes depressed after he sends his brother on an errand that results in his death after a traffic accident occurs. He blames himself and is unable to work.
However, his key complaint is his inability to pray. Therapists find clinical signs of depression, such as sleep problems and appetite. The examination reveals a major depressive disorder.
Although the examination reveals a connection with experiences of loss and guilt feelings, Alan refrains from providing insight regarding the connections.
The therapists employ cognitive behavioral intervention and pharmacological treatment and after six weeks, Alan’s ability to pray returns. Allan perceives this as spiritual revival.
Case 2—The dead Rebbe’s reluctant messenger
Joel, a 23-year-old man of Gur Hasidic sect claimed that Rabbi Pinchas, a Hasidic leader who had died 4 years ago was communicating to him. Joel, who is a devoted follower, claimed that Rabbi gave him private and public instructions.
The Rabbi directed him to observe speaking fasts and read mystical writings for hours without interruptions. Therapists employed a cognitive narrative intervention that did not include pathological content.
This involved taking the patient’s system of belief and reframing visitations to help him cope better. They acknowledged private domains and asked him to avoid passing the messages to the public.
The client consulted Rebbe on the issue of passing messages to the community. He was also given tranquilizers to lower his anxiety levels.
Case 3—The punishing angel (Witztum et al., 1990a)
Ezra, a 24-year-old man exhibited strange behaviors such as self-mortifications and hearing voices after his daughter was born. He was diagnosed with major depression characterized by psychosis. Ezra felt guilty for his alcoholic father’s death.
The night that his father died, Ezra declined sitting beside his father as his father had requested. He gave him a glass of water and walked out.
Out of guilt and depression, he started using drugs. Getting a baby girl made his condition worse because he hoped to get a son that would remind him of his father. Therapists targeted the angel that appeared to demand that Ezra harm himself.
They formed a small Jewish court to summon the angle. Ezra’s brother demanded that the angel never appear again. In the coming therapy sessions, Ezra’s condition improved.
The cases show how mystical and religious beliefs construct and shape idioms of distress, which appear as dramatic narratives that provide a voice to personal suffering. They derive their features from social milieu, symbols and Jewish narrative genres.
Fundamentally, they show that culture, interpersonal and personal factors shape idioms of distress. In this regard, to plan cultural-sensitive, narrative interventions, therapists need to ‘read’ the idioms correctly and comprehend the processes that shape dramatic narrative.
This also goes for examining cases using multi-dimensional perspectives. Such perspectives include phenomenological, psychodynamic and biological perspectives.
For instance, from a psychodynamic perspective, the first case shows a connection between guilt feelings and losing a brother, and depression signs and inability to pray. From a phenomenological approach, Ezra dissociates from his true personality and acquires the angel’s alter-personality.
Whichever the approach, cultural and symbolic background should be considered. In all the cases, therapists use cultural sensitive approaches, such as symbolic healing and co-therapists.
For instance, during cognitive narrative, therapists do not confront Joel’s behavior, but join the narrative of distress to reframe situations. In addition, delusional beliefs, including angel visitation are not confronted. Therapists help patients to ‘dialogue’ with the angels.
Ultimately, this shows that the basis of the cultural sensitive approach is acquiring patients’ cultural knowledge and respecting their traditions and culture during interventions.
Witztum, Eliezer, and Jacob T. Buchbinder. “Strategic Culture Sensitive Therapy with Religious Jews.” International Review of Psychiatry 13 (2001): 117–124. Print.