The Gur Hasid trembled in pain as he spoke about a family gathering held at Purim. One daughter in the extended family, a married woman with children, attended the big holiday meal after a long period in which she had remained secluded in her home. "We were shocked," the man recalled. "At the beginning, we could barely identify her. This is a woman who has always been blessed with a lively, expressive personality, but now it looks like pills have finished her off. We met an apathetic woman who has a solemn, stony face; a woman who has had the life sucked out of her."
The man says the family has known for years that the woman has been "shelled," as he put it, with low dosage antidepressant and antianxiety medication prescribed by a psychiatrist to whom she was referred by rabbis and various Hasidic functionaries. But up to now, nobody in the extended family had witnessed firsthand the effects of this treatment.
"The sole reason why the woman was brought to a psychiatrist, against her will, was marital discord," the man explained. At first, she adamantly refused to take the pills prescribed her, but "she had no chance of persisting in this refusal, owing to the heavy pressure exerted on her by the rabbis."
The ultra-Orthodox man says the woman's husband belongs to a well-connected family in the Gur community, and so the man's family attached "responsibility" for the situation in the house to the woman, and demanded she receive medication. "She was told that the Gur Rebbe wants her to take medication, and that the pills would restore order to her home. Nobody knows whether the rebbe really said that, but this is what persuaded her."
As a result of the Haaretz report two weeks ago ("Rabbi's Little Helper," April 6 ) - about the conferral of psychiatric medication at the request of rabbis and Orthodox activists, for purposes described as "spiritual" rather than medical - a number of persons turned to Haaretz with their personal stories.
The Hasid from Bnei Brak presented his story as part of a trend of Orthodox referrals to private psychiatric clinics as a result of internal communal issues - typically family cases. Such referrals often override the patients' own desires; usually, he patient does not really understand the nature of the treatment. Psychiatrists and psychologists also approached the newspaper, and reported cases of unethical uses of medication.
For the patient's welfare
The "Rabbi's Little Helper" report featured testimony given by Orthodox, Hasidic Jews who claimed they were needlessly prescribed medication. They showed prescriptions for antidepressant and antianxiety pills prescribed for diseases they say they never had.
Prof. Omer Bonne, director of the psychiatric department at Hadassah University Hospital, Ein Karem, was interviewed in this initial report. Like other psychiatrists mentioned in the report who treat several Orthodox patients in private clinics, Prof. Bonne claimed that he operates on the basis of purely professional considerations, and strictly upholds medical ethics. Yet Prof. Bonne adopted what he called a professional position sanctioning the possibility of prescribing antidepressant pills from the SSRI family (most commonly used for the treatment of depression, anxiety disorders and some personality disorders ) for yeshiva students who masturbate excessively, or have sexual relations with other men, yet do not suffer from depression.
Bonne justified the use of these pills by pointing out that their side effects reduce sexual urges; he argued that such medication preempts possible destructive conflicts between the men and their surroundings, and the pills might also preempt conditions of depression.
A prominent psychiatrist cited in the report justified the use of lithium - medication ordinarily used for bipolar disorders - in certain cases where a man or woman suddenly decides to stop observing religious commandments, or to break up the family unit. The psychiatrist said that in some cases, such behavior derives from conditions such as mania.
Bonne and other psychiatrists confirmed that some of the patients come to clinics accompanied by rabbis or various "supervisors" associated with yeshivas. Sometimes, the religious pupils' families are not notified of these visits. The psychiatrists confirmed that the rabbis or supervisors are on hand when patients are examined.
The report caused a firestorm in the Haredi public and the medical profession. Prof. Avinoam Reches, chairman of the Israel Medical Association's ethics committee, said he is considering convening a panel meeting to discuss the report's findings. "The doctor's role is to serve the patient's interests exclusively, and not to promote the needs of a particularly social network," Prof. Reches said. "This holds true with the ultra-Orthodox network and its attempts to control an individual. There is here a clear infringement of the individual's right to autonomy and the nullification of free choice, not to mention the stifling of sexual urges which are, in my opinion, one of the main motivating forces of human behavior.
"This is basically a process in which rabbis - with the help of various loyal intermediaries - and, much to my regret, also physicians, use medication to fashion the desires and behavior of an individual so that he fits into a social framework," he continued. "I think that doctors who behave in this way violate medical ethics."
Prof. Moshe Kotler, chairman of the National Council for Mental Health and incoming chairman of the Israel Psychiatric Association, said he will soon initiate a professional discussion on this subject in both organizations. "This report was disturbing, and we will not overlook the findings it presents," Prof. Kotler said. "I'm not talking about the individual level, because we are not a tribunal, and I personally know Prof. Bonne and Prof. [Avi] Weizman [who were mentioned in the article]. These are outstanding professionals in every respect."
Prof. Kotler added: "We will discuss the central question of to whom a professional has to remain loyal. There is no question that his main obligation is toward the patient. We do not believe that psychiatry and psychiatric medication are designed to fashion behavioral traits endorsed by particular communities, or television programs, or anything else. That is our position. I can promise that if the need arises, we will formulate the appropriate guidelines on a professional position paper."
A key figure in this controversy, who has maintained a firm silence about its findings, is Deputy Health Minister Yaakov Litzman, a Gur Hasid. He adamantly refused to respond to the original article.
In the past, Litzman has gone on record as saying he would like to establish psychiatric departments that cater to the needs of the Haredi community. Haaretz has learned that the Health Ministry has authorized funding for 20 beds in a new psychiatric care wing that is to be built in Hadassah University Hospital, Ein Karem; male and female patients will be separated in the hospital wing. Prof. Bonne, who treats Haredi patients at his private clinic, directs the Ein Karem hospital's psychiatric department.
Though Litzman has kept quiet, a debate has raged in the Haredi community about the article - including individuals and groups in its Gur (or Ger ) Hasidic branches. Gur sources say the community's leader, the Admor of Gur, is deeply engaged with the report, but the sources add that no changes are likely to be adopted by the Saving the Generations Foundation - the internal Hasidic nonprofit that maintains connections with private psychiatrists on behalf of members of the Gur community.
Hasidic sources say that last week, toward the end of the Passover holiday - a time when thousands of Gur Hasids congregate around the Admor - the report about pill-taking dominated discussions. Rabbis tried to identify persons who used false names in the report, while other members of the community began to discuss the key ethical issues raised by it.
A popular ultra-Orthodox website, Behedrey Haredim, opened a discussion on the topic, but it was quickly closed. Another discussion, called Haaretz, remained posted on the site and described the report as a "purely anti-Semitic investigation" - this description provoked dozens of responses. Some respondents in the online forum described the report's findings as "urban legends."
Another discussion has been staged on the "Stop Here and Think" page, which can also be found on the Behedrey Haredim site. Some online posters claimed the prescription of psychiatric pills can be likened to blows delivered to a person in accord with a rabbinical court decision - citing cases when they say Jewish law permits such blows to be leveled, as in the case of a husband refusing to give a religious writ of divorce (a get ) to his ex-wife.
It's uncertain whether such discussions will bring change, and some signs suggest nothing has really changed. A senior psychiatrist who directs a mental health center told Haaretz about a patient who approached him this week, after being treated by another reputable psychiatrist. The first psychiatrist reported that the patient came with his parents, and complained about "problems with the sacred" - meaning relations with other men.
According to the senior psychiatrist, the patient "is definitely not a homosexual, but he said in his yeshiva that something had happened to him. A yeshiva supervisor took him to a psychiatrist, without his parents' cognizance. A third party took care of the payment. This psychiatrist examined the young man, and prescribed anti-psychosis and antidepressant medication. The patient says that this psychiatrist did not tell him what the pills are for, but intimated that 'It will be very dangerous not to take the medicine.' The man took the pills for a month, but then quit. He felt that something was wrong, and so he came to me."
Asked how he knows that the first psychiatrist prescribed pills without any legitimate medical cause, the senior psychiatrist replies: "I examined the patient and he has no signs of psychosis or depression. It seems to me that this [first] psychiatrist was in contact with the persons who brought the patient to him, and prescribed pills without cause. I am stunned that people do that. The young man did not pay for the meeting with the psychiatrist, and everything happened with the parents' knowledge."
This week, senior psychiatrists addressed the question of why colleagues might prescribe antidepressant or antianxiety medication for symptoms that have nothing to do with depression or anxiety, and why they might oblige the demands of third parties. One stated that the "roots of evil" are the private clinics. Another opined that such psychiatrists "genuinely believe they are helping their patients by preempting various complications and reducing suffering."
Prof. Kotler, the only psychiatrist who agreed to be interviewed openly in this report, stated, "What we have here is an encounter between stigmas. There is in the Haredi community a stigma against referrals to mental health professionals; anyone who turns to a psychiatrist is stigmatized. On the other hand, there are stigmas against certain forms of behavior, traits that are accepted in other communities. All this creates a gray area, in terms of consciousness and awareness. I think the Haredi community is becoming more open toward receiving mental health care, yet stigmas about the subject remain very strong. So it must be established very clearly that pills are not a pickax used to dig around and explore; their sole purpose is to attend to a patient's suffering."