Cultural Sensitivity Training in Mental Health: Treatment of Orthodox Jewish Psychiatric Inpatients ELIZABETH SUBLETTE Department of Psychiatry Hillside Hospital, Long Island Jewish Hospital BARUCH TRAPPLER Department of Psychiatry State University of New York, Health Science Center at Brooklyn Address correspondence to Baruch Trappler, State University of New York, Health Science Center at Brooklyn, Department of Psychiatry, 450 Clarkson Avenue, Brooklyn, NY 11203 ABSTRACT. We describe some of the cultural/religious issues which arose in the treatment of major psychiatric disorders among Orthodox Jewish inpatients at SUNY Health Science Center’s University Hospital (SUH) in Brooklyn, New York. The distinct ways in which cultural and religious factors impacted on presentation, therapeutic interventions, and transference- countertransference reactions are noted. Specific reference is made to the use of religion by patients and families as a means of defense, rationalization or power-brokering. Via case vignettes, we explore ways of distinguishing between culturally appropriate vs. maladaptive behaviors in the Orthodox population. Practical solutions are suggested for sensitive ways to surmount culture-based barriers to effective inpatient therapy in this group. OVER THE LAST 50 YEARS, the importance of ethnocultural factors in the psychotherapeutic process has been increasingly studied (Devereux, 1953; Ticho, 1971; Griffith, 1977; Comas-Diaz & Jacobsen, 1991). Although some authors have described culture-specific aspects of psychiatric treatment of Orthodox Jews (Bilu & Witztum, 1993; Witztum, Greenberg, & Buchbinder, 1990; Mintz, 1992; Ostrov, 1978; Paradis, Friedman, Hatch, & Ackerman, 1997), little has been published concerning issues of inpatient treatment of this population (Trappler, Greenberg, & Friedman, 1995). While the term ‘Orthodox’ embraces a range of religious practices, with a number of ethnic and idealogic sub-groups, for the purposes of this article the term ‘Orthodox’ will refer to those Jews whose Eastern European cultural background and strict interpretations of Torah law have led to the greatest separation from the values of secular society1. For such patients, issues of cultural sensitivity would presumably have the largest impact. During the period 1994-1998, we treated 15 Orthodox patients from the nearby Brooklyn community on the psychiatric inpatient unit at SUH, a 30-bed voluntary unit, with an average length of stay of about 30 days. Patients consisted of 11 males and 4 females; mean age was 36.7 1 This group includes both Hasidic and non-Hasidic Jews. For more information concerning Orthodox sub- groups, see Mintz, 1992. years. Patients had the following diagnoses: schizophrenia, 6 patients, schizoaffective disorder, 3 patients; bipolar disorder, 4 patients; major depressive disorder, 2 patients. Diagnosis was made by structured interview using DSMIV criteria (American Psychiatric Association, 1994). Staffing consisted of 3 full-time psychiatrists (one of whom [B.T.] is Orthodox), 3 part-time psychologists, 2 psychology fellows, 5 psychiatric residents, 2 social workers, a full-time family therapist, nursing staff and 3 full-time activity therapists. In addition, a variety of trainees worked on site, such as medical students, activity therapists, and psychology interns. On the unit, emphasis was placed on combined therapies, including pharmacotherapy; psychodynamically- oriented individual, group, and family therapies; and a variety of therapeutic activities such as arts and crafts, music and cooking. All staff and patients also attended large community meetings three times a week. The other inpatients were of widely diverse cultural, racial and socioeconomic backgrounds, reflecting the multiethnic population found in Brooklyn, NY. Case histories have been altered in non-essential details to protect the privacy of the patients. Integrating Orthodox Patients into the Milieu Therapy The practice of Orthodox Judaism is extremely structured and regulates all activities of daily life. For example, each day contains mandatory periods for prayer. Adult Jewish men are also required, during morning prayers, to put on phylacteries (“tefillin”), ritual objects consisting of two leather boxes containing Biblical verses, which are affixed to the forehead and one hand by means of long leather straps. Ritual pervades even mundane activities such as meals, which must be kosher, and which are preceded and followed by ritual washing of the hands and blessings. Our unit is a treatment setting where scheduled groups and activities are considered important in providing structure for disorganized patients. Patients meet with occupational therapy staff each morning to assign officer positions for community meetings, to discuss privilege levels, and to receive their schedules for activity and group therapy meetings. Those with privileges can participate in walks and gym activities twice a week. Under these conditions, the schedule may run counter to the religiously-determined daily activities of the Orthodox patient. In such cases, the inability to pray at accustomed times with phylacteries could exacerbate the anxiety of the religious patient. The objective of providing structure through community activities may thus potentially become counterproductive for the Orthodox patient, as a result of the clash of milieu and religious cultures. On the other hand, the need for adherence to prayer schedules can potentially become a way for patients to distance themselves, avoid social interactions, or feel stigmatized as different from their peers. Furthermore, it may be difficult for non-Orthodox hospital staff to determine the true extent of normal ritual versus hyperreligiosity or pathologic prolongation of ritual functions. Our major cross-cultural therapeutic goals, therefore, included integrating the Orthodox patients into the milieu environment and allowing legitimate religious practices while setting limits on maladaptive ritual. Where possible, religious rituals were honored. For instance, the Orthodox patients were provided with kosher meals but were expected to eat in the main dining room with the other patients; male patients were allowed to bring in their phylacteries to be used under supervision, provided they were not too disorganized or on suicide precautions; and particular times for study and prayer were allowed, as long as they did not conflict with the unit’s schedule. Patients were given time for prayer but were expected to show some flexibility where this conflicted with unit schedules, which would take precedence; they could pray before or after, but not during, community meetings. Six out of our group of fifteen patients displayed involvement with ritual which conflicted with milieu activities. These included ritual hand washing, study, and prayer. Two very regressed schizophrenic patients were frequently involved in compulsive rituals which shielded them against the threat of social stimulation. A. was a 35-year-old schizophrenic man with a long history of hospitalizations at acute and long-stay facilities; he had never completed high school. The patient was disorganized, poorly groomed, and his room was in a state of disarray. He would easily become overwhelmed and overstimulated in community meeting. During these times, he immersed himself in prayer and stated that his religious needs did not allow him to attend the meeting, or that he could not attend because he was “studying to be a rabbi.” As his neuroleptics were titrated, he gradually tolerated longer periods of exposure to community meeting, accompanied by a trusted staff member, and eventually made relevant verbal contributions. The Jewish Sabbath begins Friday night just before sundown and extends until Saturday evening. During this time period, Orthodox Jews are not permitted to engage in many of the recreational activities that take place on an inpatient unit, including watching television, listening to radio, turning on electric lights, writing, cooking, or creative arts. Similar prohibitions pertain to Jewish holidays, many of which last two days. During these times, patients’ families cannot visit if they live farther than walking distance from the hospital, due to the prohibition against any form of motorized travel. Just as non-Jewish patients can be expected to experience difficulty in being away from their families over major holidays, so too Jewish patients find it depriving to be hospitalized during Sabbath and holiday times. Although observing the various Sabbath prohibitions may be possible on an inpatient unit, the patient will miss most of the positive aspects of the Sabbath day, which at home is spent with communal immersion in study, prayer, and festive meals. Cultural sensitivity with regard to the Sabbath included permission for patients to light Sabbath candles in the activities room, under supervision, and granting of relative-accompanied passes for Sabbath and holidays whenever possible, even when they conflicted with unit schedules: B. was a 40-year-old single woman, schizophrenic, whose mother had also been schizophrenic and had died 8 years previously. The patient had the responsibility of being the homemaker for her father, who is a prominent rabbi in the community. On arrival on the unit, B. was disorganized and required frequent observation. Her father would visit on the Sabbath. By the time the Jewish holidays arrived, she had been on the unit for 3 weeks. Her father was able to escort her on a 4-hour pass to