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........Sigmund Freud, the "father" of modern psychology and psychotherapy, and the most influential figure of psychology, openly referred to himself as "a Godless Jew", disavowed himself from his Jewish heritage, and termed religion a "neuroses of the masses" (Gay, 1989). Since then, much of Freud's theories have been challenged and refuted. Today, the trend towards Freudian theory is skepticism, "sometimes even questioning the usefulness of studying it at all (Fancher, 1973)." In contrast to that trend, today there are many practicing psychologists who are religious, orthodox, Jews. These psychologists abide by the rules and regulations of their profession, and also faithfully follow their religious convictions. Often, psychology and the Jewish religion can be synthesized harmoniously - and at times even complement each other. There are moments, however, when they collide. The professional ethics and regulations of psychology may clash with the religious duty of a God fearing Jew. In some cases a compromise can be attained, in other cases an allegiance to one side must be made - at the cost of the other. An orthodox Jew however, must always side first and foremost on the side of religion. The following is a letter (Sirote, 1997a) I posed to an electronic-mail discussion group (called Jewish-psy) which consists mainly of Jewish Psychologists and Rabbi's - their responses to this letter spurred some of the most passionate reactions in the history of the group:

..........Dear Friends, I am currently writing a paper about the ethical conflicts than an orthodox ..........therapist faces. An example would be where a Jewish woman, during a marriage counseling ..........session, reveals to her therapist that she once had an affair. According to Orthodox Jewish ..........law that couple is no longer allowed to stay together. If the therapist continues counseling this ..........woman he may help alleviate the marital problems and thus perpetuate this forbidden ..........relationship! Should the therapist terminate therapy at that point? Doesn't the therapist have a ..........professional commitment to consider, as well as the well- being of his client?! ...... I am also ..........interested in actual case examples. If you have fond yourself in similar ethical/religious ..........conflicts please share what that was and how you dealt with it...."

It is these types of ethical conflicts that will be the focus of this paper.

.....Adultery. The issues involved in counseling couples for marriage and sexual problems are among the most complicated and difficult for an orthodox therapist to undertake. This is mainly due to the traditional (read: strict) views of orthodox Judaism on those issues and the severity with which Judaism views adultery. The prohibition against adultery is succinctly enumerated in the Bible as the seventh of the Ten Commandments where it says "Thou shalt not commit adultery (Exodus, 19:13)." In Biblical times the punishment meted out to Jewish adulterers was capital punishment through stoning! Throughout Jewish history, numerous laws and issues dealing with family purity and marriage have been written. Six volumes of the Talmud (one of the most important and revered works in Jewish Literature), encompassing hundreds of pages, are dedicated specifically to these issues. Thus, the therapist involved in marriage counseling cannot take any situation that arises lightly. If, during the course of therapy with a Jewish couple, it comes to the attention of the therapist that adultery was committed (as per the scenario addressed in the aforementioned letter - or any similar case) there are many issues to consider. Dr Sylvan Schaffer (1984) enumerates some of the issues involved. To begin, according to Orthodox Jewish law, an adulteress is forbidden to return to her husband after the affair has occurred. Thus, if the marriage counseling continues, and is eventually successful, it would aid in the perpetuation of this now forbidden marriage. In addition, if the woman admitted her infidelity to the therapist in a private session without the husband, it would be a violation of her confidentiality to tell her husband that she had an affair (Ethical Standard #5 of The American Psychological Association's Ethical Principles and Code of Conduct, as quoted in Bersoff, 1995). There are three basic options the therapist has in such a case, each solution posing its own unique problems:

1. Continue with the professional commitment and allow the counseling to continue. The problem with this option is on the side of religion - the therapist is allowing, and even helping, a forbidden marriage to perpetuate. For the orthodox therapist this is an unacceptable solution.

2. Terminate therapy. It is a marriage that you cannot sanction and hence you remove yourself from any involvement with it. The problem with this option is on the side of professional ethics. It can be psychologically damaging to a client to suddenly terminate therapy in the midst of counseling, especially after trust and intimacy with the therapist has been established, and a commitment has been made. Additionally, to cause someone pain, and abandon them in their time of need is problematic according to Jewish law itself - thus, this option is also unlikely to be followed.

3. The third option - perhaps the most radical, involves neither perpetuating the marriage, nor terminating therapy. It stems from another biblical law (Leviticus, 19:17) - "and you shall rebuke your neighbor [when they have sinned]." This option would entail informing them that they are involved in a forbidden relationship and dealing with the consequences from there. This solution does appear to be a harsh one, and is replete with problems in its own right - as Dr. Eduardo Kleiner (1997) puts it "the client is usually not seeking a moral advisor or judge". Nevertheless, for the orthodox therapist, Jewish law must take precedence.

Before the therapist decides upon which option to undertake, Dr Sylvan stresses that a Rabbinic authority of Jewish law must be consulted, and every angle must be analyzed.

[Later, I outline some ground rules for the orthodox therapist to discuss with his clients before any therapeutic session begins. These ground rules, hopefully, aid in avoiding many of the problems involved in such a case.]

.....Masturbation. Dr Scaffer also discusses another aspect of marriage counseling - the treatment of problems related to physical intimacy and sexuality. For example, a common (and highly successful) method of treating impotence, premature ejaculation, and lack of sexual desire is to use systematic desensitization. This is where the client gradually lessens his anxiety through imagining the scene, coupled with masturbation and relaxation exercises, until he can actually perform intercourse itself. Sanctioning this type of treatment is highly problematic to the orthodox Jew because an intentional arousal and "wasting of the seed in vain" (read: masturbation) is forbidden for the Jewish male! However, Dr. Sylvan explains that according to some rabbinic authorities, this form of treatment would be permissible. The rationale for its permissibility is as follows: the client, in this situation, is engaging in masturbation for the specific purpose of treating a dysfunction and is, therefore, not "wasting his seed in vain", so to speak, but is instead doing it for a true purpose (to be able to resume his permissible marital relations).

.....Homosexuality. Another conflict within the sexual domain involves homosexuality. As opposed to the newest versions of the DSM, and modern psychological theory, Judaism still (and forever) considers homosexuality to be a perversion, and cannot condone it in any way. "Thou shall not lie with a man in the same manner as with a woman; it is an abomination (Leviticus, 18:22)." Rabbi Moshe Halevi Spero (1986) adamantly states:

....."The halakhically [Jewish law] - observant mental health professional cannot treat homosexuals .....who wish to be accepted as homosexuals or to have their sexual life-style 'improved' or even .....condoned. He also cannot refer such individuals to other professionals, Jewish or non-Jewish, .....who will accept the homosexual on such terms..."

Clearly, as "unpolitically correct" as that stand is, it is the one the orthodox Jewish therapist must take.

[It should be noted, however, that homosexuals, when not seeking acceptance of their lifestyle, they "should be treated medically and psychosocially no differently than other patients, and physicians and other medical personnel are obligated to heal patients with AIDS (Rosner, 1987)."]

.....Guidelines In order to avoid many of the problems that can arise between a Jewish therapist and his patients, basic guidelines and ground rules should be laid down at the start of therapy. Dr. Michael Bernet (1997) suggests that the therapist discuss the following with his/her clients at the outset of therapy: "if you tell me something about yourself which I believe is contrary to Halacha [Jewish law] , I may point it out to you and you may wish to act on the Halacha or not." In cases with severe violations of Jewish law the therapist might go so far as say "I may point it out to you and I will expect you to act on the Halacha; if not I may have to terminate this treatment." Other issues to discuss, before commencing with treatment, should involve an agreement on which authority of Jewish law they will seek out in case a question of Halacha arises. Indeed, Dr. Daniel Eidensohn (1997) states that "every therapist needs to form a partnership with a competent Rabbi who is experienced in dealing with psychological issues." He continues that the rabbi "will benefit from your expertise in psychology and you from his knowledge of Jewish law. Taking this a step further, Dr Shlomo-Zalman Jessel from Hebrew University in Jerusalem (1997) encourages the therapist, besides forming a partnership with a rabbi, to become as knowledgeable about Jewish law and philosophy as he can for himself.

.....Clinical Examples. The responses that I receive to the letter that I submitted to the Jewish-psy email group contained many psychologist's actual clinical cases that dealt with these types of issues. To demonstrate that these ethical conflicts are living, breathing issues, and not just theoretical, I will briefly summarize a few interesting cases.

Case 1: Dr. Solomon Schimmel was seeing a Jewish woman for depression, who was very unhappy in her marriage. The woman and her husband had both become religiously committed and observant over the past few years, accepting upon themselves the authority of Jewish law. One of the dissatisfactions with the marriage was sexual frustration. There had been times when the woman's sexual needs had been satisfied by the husband engaging in oral sex, which the husband was now unwilling to engage in, since he had been informed by his rabbis that such practices were frowned upon in Judaism. The wife was conflicted about pressuring him to behave in ways that contradicted his beliefs. Dr. Schimmel was conflicted with his own view of the situation. He felt that if these forms of sexual interaction would have made a significant difference in satisfying the wife's needs, then a case could have been made for a more liberal approach towards engaging in oral sex. However, the husband insisted that he did not want to violate the spirit of the law as it was formulated to him by the rabbis with whom he had consulted. [Dr Schimmel did not reveal the outcome of this case.]

Case 2: A therapist tells of a Yeshiva student contemplating suicide. He was an intelligent student who had been bisexual prior to becoming religious. He was now studying the Talmud full time in a Yeshiva and had several children. His wife did not know about his past. His main problem was that he could not get certain images and feelings out of his head whenever he saw a handsome male. The conflict the psychologist had was with the man's rabbinical mentor. The rabbi, who knew all about his past, told him that the way to overcome his problems would be to study harder. The therapist, on the other hand, felt that there were much deeper issues involved and that burying it in his studies would not be sufficient. Relaying his disagreement with the student's rabbinical mentor, however, was a very complex situation - after all, one's rabbinical mentor is highly regarded and revered. Eventually, the therapist managed to suggest to his client that he should transfer to a different environment where he would get more intensive attention for his problems. The client ultimately listened and, in time, was able to resolve his problems.

Case 3: [This case is the basis for the hypothetical case that was outlined earlier.] For three years a young man took room and board at the home of a certain family, during which time he was carrying on a clandestine affair with the wife of the couple with whom he was staying. Subsequently, he repented his behavior and became engaged to the couple's daughter! The woman with whom he had the adulterous relationship was now forbidden to her husband. Did the young man, having repented, have to tell the husband (his future father-in-law) that he should discontinue living with his wife? An additional question was what if he told the husband, but the husband nevertheless continued to stay married to his wife, refusing to divorce her. Did he have to tell the Jewish court (the "Beth Din") of the city which would force him to break up his marriage?

.....Another interesting issue which faces an orthodox therapist is one involving the law of Yichud - the religious prohibition of a man and a woman being alone together if they are not married. This law is very complex and has many variables, but has a simple concept. According to the law of Yichud a man and a woman are not allowed to be alone anywhere together unless they are married - thus, an unmarried male and female could not walk into a room alone and lock the door behind them. Rabbi Azarya Berzon (1987) explains the reasoning behind this prohibition is to preclude any illicit sexual encounters from occurring. Take a religiously observant couple that is engaged to be married. If they are never fully alone together until they are married, then the chances of them "slipping up" and engaging in a sexual encounter (any sexual contact before marriage is strictly forbidden in Orthodox Judaism) is minimized. This law, however, poses certain problems for a therapist. In most cases of therapy, the therapist will be alone in a room with the client, usually locking the door which ensures maximum privacy, avoids intrusions, and facilitates a safe, open, and intimate atmosphere. The problem encountered is that, if the therapist is female and the client is male (or vice versa), then they are alone in a locked room, thereby violating the prohibition of Yichud. Rabbi Berzon offers some suggestions on how to overcome this problem, but still maintains that total privacy between them is definitely prohibited. One method of overcoming this problem is as follows: close the door of the room so they can be alone, but without locking it, and make sure that there are other people in the office area or waiting room. Another way around this problem is to lock the door, but have the key to the room in the hands of someone in the area who can theoretically open it at any time.
.....These suggestions allow for the therapist and client to be alone, and at the same time eliminate the problem of them having total privacy.

.....Another issue that the orthodox therapist has to be aware of is an emergency psychiatric consultation that may lead to a violation of the Sabbath. This may occur when an orthodox therapist's patient threatens to commit suicide. The therapist may need to pick up the phone or drive his car to the hospital to aid his client - both of which constitute violations of the Jewish Sabbath. Another scenario may involve young children who need to undergo a serious surgical procedure on the Sabbath, but are being uncooperative and resistful. A therapist may need to be brought in without delay to help raise their level of cooperation and alleviate their anxiety. These issues are especially salient in Israel, where the vast majority of psychologists are Jewish, and thus, finding a non-Jewish psychologist for emergency consultation duty on the Sabbath is not always feasible. Rabbi Moshe Halevi Spero (1986) explains that in cases such as these we are almost always lenient because we regard a persons life and health to be more valuable then observing the Sabbath! The Sabbath can thus be violated if someone's life or health was in danger.

.....Interestingly, in a related case, we allow the husband of a woman in labor to accompany her to the hospital (by riding in a car) even if he may come to violate the Sabbath. What is compelling is that in this case, although the husband himself is in no danger himself, he is allowed to violate the Sabbath and travel with his wife so that she can feel safe, and not have to go through the delivery alone - when she will desperately need his support.

.....An issue that is unique to the orthodox (male) therapist is one involved with wearing a Yarmulke (Jewish skullcap) during therapy sessions. For Jewish clients, a Yarmulke can evoke powerful transference issues related to religion. For the non-Jewish client it can be intimidating or distracting. I recall a story a social worker related to me about a session involving a young African-American boy. Throughout the session, the boy was trying to peep at the top of the therapists head to try and get a glimpse of exactly what it was that he was wearing on his head. Midway through the session, the therapist realized what the boy was doing and asked the boy if he would like to see what it was. When the boy responded positively the therapist took it off and handed it to the boy. The boy squealed in delight "ohh, it's so soft (the therapist was wearing a velvet Yarmulke that day)!" After that exchange, the young boy was much more comfortable, and a productive session ensued.

.....In researching this issue I found almost no literature pertaining to this subject and so I, again, turned to my colleagues in the Jewish-psy group. I posed the following letter (Sirote, 1997b):

..........I'm Curious. Relating to the previous topic we discussed (concerning the ethical conflicts that ..........can face the Jewish psychologist) is the issue of an orthodox therapist wearing a Yarmulke ..........during therapy sessions. Has anyone found wearing a Yarmulke to be a source of problems ..........or ill-feelings in therapy? Do non-Jews view you (at least your skills as a therapist) in the ..........same light as Jewish clients? How about in Israel where wearing a Yarmulke is accepted and ..........normal - do non-Yarmulke wearing clients approach Yarmulke-wearing therapists ..........differently?
..........I am currently interning at Creedmorr Psychiatric Center in New York, working mainly with ..........chronic schizophrenic and borderline patients, and always wear my Yarmulke. It is ..........(obviously!?) the first thing that the patients notice when they see me. The comments that start ..........flowing run the gamut from "are you Jewish?" to ramblings about Hitler and cultural slurs...No ..........matter what ward I enter someone invariably starts sermonizing about God, redemption, and ..........Jesus.
..........I realize that my setting is at one extreme and I am curious as to how the "normal neurotics" ..........deal with Yarmulke wearing therapists. Sharing your experiences would be appreciated.

What ensued was a flurry of responses which I will summarize here.

....Dr. Elihu Turkel (1997), senior psychologist at Long Island Jewish Medical Center, responded that usually when a patient comments on his Yarmulke right away, it is diagnostic of a psychotic disorder. He explains: "I think that the Yarmulke is a strange projective stimulus; it is not ambiguous - it definitely pulls for attitudes and associations about religion, authority, rules, morality, etc., but it taps different content and attitudes for different people. The ideational matrix that it pulls is usually highly charged and, so, people with weaker social constraints and/or appreciation of social nuance are more apt to express these ideas in 'real time'. My 'neurotic' patients usually take much longer to bring up these issues (if ever)." Thus, how a client reacts to a Yarmulke can actually offer some personality clues about the person reacting to it.

.....Another interesting response was offered by Dr. Steve Adelman (1997). He reports how he started wearing a Yarmulke a few years ago while working with heroin addicts. He relates how the addicts were particularly interested in the fact that their doctor was going through some form of spiritual transformation at the same time they were struggling to go through some form of transformation of their own - through the "12 Steps" program. Many of them also articulated a sense of reassurance and encouragement by being in treatment with someone who is clearly a "believer" (after all, he wears a Yarmulke) and is comfortable with sharing that with the world.

.....Dr. Adelman also goes on to say that a Yarmulke, in some ways, acts as a Thematic Apperception Test (T.A.T.) for Jewish patients. Judy Gradinger (1997) of the Jewish General Hospital in Montreal expounds upon the Yarmulke-as-T.A.T. analogy by explaining that a Yarmulke (like the T.A.T.) "brings up and out" stories in the client. She writes that "it probably stimulates memories and encourages the patient to think about, and perhaps discuss, these past associations."

.....Indeed, it would appear that wearing a Yarmulke can bring out powerful associations upon a client, and can even allow for certain insights based upon their reactions. Further research and discussion should definitely be undertaken in this area to fully discover the range of transference affects, associations, evocations, and other issues associated with a Yarmulke-wearing therapist.

.....The unique issues discussed in this paper must be broached and faced by any serious orthodox therapist. The numerous replies to my queries in the Jewish-psy email group reinforces the fact that these issues are not just theoretical, and are faced by psychologists every day in the "real world". In truth, many of the issues discussed here, have ramifications beyond the world of the orthodox or religious therapist. Any psychologist who has strong beliefs, feelings, and opinions, towards major issues of life (which is just about every person out there) must take into account how those issues affect him, and his clinical skills, when he encounters a client who shares or violates those beliefs.

Adelman, Steve (1997). Yarmulke Transference. Jewish-Psy Email Group. 4/2/97. Available via .....Email: Jewish-psy@shamash.nysernet.org

Bernet, Michael (1997). Jewish vs. Psychological Ethics. Jewish-Psy Email Group. 3/11/97. .....Available via Email: Jewish-psy@shamash.nysernet.org

Bersoff, Donald (1995). Ethical Conflicts in Psychology. American Psychological Association, .....Washington, D.C.

Berzon, Azarya (1987). Contemporary Issues in the Laws of Yichud. The Journal of Halacha and .....Contemporary Society, number 13, 79-112

Eidensohn, Daniel (1997). Jewish vs. Psychological Ethics. Jewish-Psy Email Group. 3/12/97. .....Available via Email: Jewish-psy@shamash.nysernet.org

Fancher, Raymond (1973). Psychoanalytic Psychology The Development of Freud's Thought. New .....York: W. W. Norton and Company

Gay, Peter (1989). The Freud Reader. New York: W&W Norton & Company.

Gradinger, Judy (1997). Jewish-psych: "projectives". Jewish-Psy Email Group. 4/3/97. Available .....via Email: Jewish-psy@shamash.nysernet.org

Jessel, Shlomo-Zalman (1997). Values Conflict in Therapy. Jewish-Psy Email Group. 3/18/97. .....Available via Email: Jewish-psy@shamash.nysernet.org

Kleiner, Eduardo (1997). Jewish vs. Psychological Ethics. Jewish-Psy Email Group. 3/11/97. .....Available via Email: Jewish-psy@shamash.nysernet.org

Rosner, Fred (1987). AIDS: A Jewish View. The Journal of Halacha and Contemporary Society, .....number 13, 21-41.

Schaffer, Sylvan (1984). Halachic Consideration In Marriage Counseling and Sex Therapy. The .....Journal of Halacha and Contemporary Society, number 7, 53-66

Sirote, Barry (1997a). Jewish vs. Psychological Ethics. Jewish-Psy Email Group. 3/10/97. .....Available via Email: Jewish-psy@shamash.nysernet.org

Sirote, Barry (1997b). Yarmulke Transference. Jewish-Psy Email Group. 4/1/97. Available via .....Email: Jewish-psy@shamash.nysernet.org

Spero, Moshe Halevi (1986). Psychotherapy & Jewish Ethics. Jerusalem, Israel: Feldheim .....Publishers Ltd.

Turkel, Elihu (1997). Yarmulke Transference. Jewish-Psy Email Group. 4/2/97. Available via Email: .....Jewish-psy@shamash.nysernet.org