The American Journal of Psychoanalysis, 2014, 74, (262–279) © 2014 Association for the Advancement of Psychoanalysis 0002-9548/14 www.palgrave-journals.com/ajp/

THE CENTRALITY OF GUILT: WORKING WITH ULTRA-ORTHODOX JEWISH PATIENTS IN ISRAEL* Esther Hess

The ultra-orthodox Jewish (Haredi) community in Israel is characterized by strict observance of the requirements of orthodox Jewish life. Psychoanalytic psychotherapy within this community brings us into contact with guilt as a central emotion throughout the therapeutic process. The exposure to new concepts, ways of thought and a previously unknown space, together with increased awareness of internal wishes and drives, are experienced as forbidden areas that arouse an awakening of conscience and a sense of guilt. The author’s cases illustrate these conflicts.

KEY WORDS: conscience; guilt; orthodox Jewish patients; religious beliefs and treatment. DOI:10.1057/ajp.2014.23

We are truly guilty … (Genesis 42:21)

In this paper I wish to explore several aspects of the feeling of guilt, particularly as experienced by patients from the ultra-orthodox Jewish (Haredi) community in Israel. Readers should be aware that I myself belong to this community and therefore I am writing “from the inside,” as it were, while at the same time observing “from the outside” in my clinical work. I believe that the duality of this position provides me with a unique perspective on psychotherapeutic work within the Haredi community, and it is from this standpoint that I discuss the various aspects of guilt considered in this paper. Esther Hess, Ph.D., is affiliated with Mayanei HaYeshua Medical Center, 15 Rav Povarsky Street, Bnei Brak 51544 Israel; Jerusalem College, P.O.B. 16078, Bayit Vegan, Jerusalem 91160, Israel; and ASA, Academic Institute of Society and the Arts (Lesley University – Israel Extension), 10 Haorazim St., Netanya 42379, Israel. Address correspondence to Esther Hess, Ph.D., Mayanei HaYeshua Medical Center, 15 Rav Povarsky Street, Bnei Brak, 51544, Israel *This paper describes material that is part of a larger research project entitled “Psychoanalytical Psychotherapy in the Ultra-Orthodox Community: Contradiction, Conflict or Possible Tension” (Hess, 2011b).

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A short vignette will provide an illustration: Several years ago, on the eve of the Jewish New Year, there was a hesitant knock on my door. By way of explanation, I should add here that the period around the Jewish New Year (Rosh Hashana) and the Day of Atonement (Yom Kippur) is not only a celebration of the beginning of a new year, but also a time for reflection and forgiveness. Jewish belief holds that at this time of the year the fate of every person in the coming year will be decided by G-d, and thus people may both seek and grant forgiveness and reconciliation during these weeks. When I opened the door, I saw L, a young girl of about 17, who had been in treatment with me for about a year, and who had ended her therapy shortly before this unexpected visit because she had moved to a distant city. L asked shyly whether she could speak to me for a few moments. I was surprised to see her and asked her to come in. I knew that she had travelled a long way and apparently there was something urgent that she wished to discuss with me. Speaking hesitantly, L asked me to forgive her for the way she had behaved during the treatment. She knew that we were close to Rosh Hashana, the Day of Judgment, and she felt that her behavior had been unruly and even “cheeky” as she put it. “I really feel that I must apologize and ask for your complete forgiveness. I was out of control, please forgive me … ” L’s unexpected visit demonstrates the depth of her feelings of guilt and the power of her need to ask for forgiveness. Guilt is a well-known and universal emotion, which knows no boundaries of nationality or religion. However, the experience of guilt, which may superficially appear as sincere self-awareness and self- examination with positive moral connotations, can be deceptive. Closer observation may reveal a different source, and there may be hidden feelings and needs underlying the sense of guilt. There is also a need to differentiate between feelings of guilt and feelings of responsibility. The Oxford Dictionary website (http://oxforddictionaries.com/) provides two definitions for the noun “guilt”: (a) the fact of having committed a specified or implied offence or crime; and (b) a feeling of having committed wrong or failed in an obligation. For the purposes of this article, we will focus on the second definition. The same website provides several definitions for the noun “responsibility,” but here we will relate to “responsibility” as “the state or fact of being accountable or to blame for something.” There is a well-known variation of guilt, which we encounter in clinical material at the clinic, and that is the guilt created by the therapeutic process itself. The patient, who suddenly finds himself at the center of his own private world, is now exposed to new, unknown areas of thought that has to potential to lead him to new discoveries and insights. During this process, the patient finds himself in a space that is somewhat different from where he was prior to the start of the therapy, even if only because time has moved on.

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This natural development of self-knowledge arouses fear and anxiety about contact with painful thoughts or insights that demand change. This fear, which in itself is entirely legitimate and an inseparable part of the therapeutic process, can give rise to guilt feelings that create an additional level of complexity in the therapy. The patient may find himself reflecting on his acts and facing a painful dilemma—whether to take responsibility for his thoughts and actions or to remain with the burden of guilt feelings. These fears and guilt feelings are greatly intensified for patients from the Haredi community, for whom the encounter between orthodox Judaism and psychotherapy raises several unique issues. Members of this community live within a framework of strict observance of the Jewish religious commandments and customs. They have an unwavering belief in G-d and believe that everything is ordained from above and that everything that happens is for the good, in the end. They believe in reward and punishment and in the power of prayer. Patients from this community who are exposed to new or previously unacknowledged feelings may be flooded with emotions. The awareness and knowledge created in the course of therapy constitute a breakthrough into the open world that enables and even encourages cognitive pluralism. At the same time, however, this encounter with a different worldview is fraught with difficulties. The very decision to come to therapy, the discussions, the insights and the experiences, and the moving on to eventual changes in thought patterns and behavior—all these stages are accompanied by guilt feelings, which remain a constant presence throughout. The following quotations from patients illustrate the sense of guilt often seen in the religious-orthodox therapeutic setting: “I’m sitting here prattling away instead of [spending my time] studying Torah … ” We hear this frequently, sometimes almost as a ritual expression. “I told you about the quarrel I had with X … Never mind, everything’s all right now, forget about it … ” Something is said and then negated, often after a wave of troubling thoughts and struggles with one’s conscience. “To be in therapy while I should be working to support my family … Is this permitted? … Am I OK? … Doesn’t this affect my responsibilities as a parent and/or as a student of Torah?” And many similar expressions of worry can be heard.

Frequently we are not aware of the feeling of guilt as such. It has a tendency to hide behind other emotions and consequently it may find expression through other emotions such as fear and shame. These concepts are beautifully illustrated in three well-known stories from the Book of Genesis: the stories of Adam and Eve, Cain, and Joseph and his brothers. After Adam and Eve had eaten from the Tree of Knowledge and their eyes were opened to know good and evil, Adam responds to G-d’s calling him

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with the words: “I heard the sound of You in the garden and I was afraid, because I was naked; and I hid myself” (Genesis 3:10). Only after Adam and Eve had disobeyed G-d’s command and they saw their act in a new light, did they hide, fearing the wrath of G-d and feeling shame for their act. Here we see that fear and shame are emotions that express the sense of guilt hidden behind them. A second example appears in the story of Cain’s killing of his brother, Abel. Cain responds to the punishment from G-d by acknowledging his deed and saying “My sin is greater than I can bear! Surely, You have driven me out this day from the face of the ground; I shall be hidden from Your face” (Genesis 4: 13–14). Here Cain expresses his shame about his crime before G-d. In Cain’s words “My sin is greater than I can bear” there is an expression of acknowledgment, regret and shame. These emotions are closely linked to the sense of guilt, and serve as a way to express it. In Judaism this is a way of striving towards “Tikkun,” a Hebrew term meaning “reparation” but which implies a continual striving towards high ethical standards as well as repentance for a lack of faith or for failing to maintain an orthodox Jewish way of life. The familiar story of Joseph and his brothers provides us with an illustration of declared guilt. The jealous brothers sold Joseph, the favorite of their father, into slavery, in spite his painful pleading with them. Many years later the brothers expressed their own inner anguish: “Then they said to one another, ‘We are truly guilty concerning our brother, for we saw the anguish of his soul when he pleaded with us, and we would not hear; therefore this distress has come upon us’ ” (Genesis 42:21). The expression “We are truly guilty” (in Hebrew Ashemim Anahnu) as used in the Biblical text above refers to regret together with a sense of guilt and culpability. At first sight this appears to be a rational guilt over the distress and the anguished cries of their brother, a reasonable and expected emotion. But despite this declaration, we should ask ourselves whether this is a regret that includes taking responsibility, or only a “beating of the breast” that contains nothing except a torment of the soul. Here too, there is a need to differentiate between these two concepts, responsibility and guilt. SOME THOUGHTS ON THE DYNAMICS OF GUILT

The discussion of the feelings of guilt from various perspectives, such as psychoanalytic, philosophical, legal or religious viewpoints, attests to the major emotional role it plays in the formation and functioning of the self. Freud (1907) described guilt as an unconscious emotion and as the need of human beings for punishment. In his view, guilt is an expression of forbidden and suppressed wishes, and it adds a layer of distress and suffering.

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Freud referred to a “punishing superego,” which contains the parental internalizations, demands and prohibitions. The feelings of guilt emanate from the superego, a concept Freud greatly expanded in 1923 and later. In the words of Laplanche and Pontalis (1973): “the superego’s role in relation to the ego may be compared to that of a judge or a censor” (p. 435). In Coltart’s (1992) reading of Freud, the superego represents our external relations with ego-ideal figures, which are gradually transformed into internalized ideals, and fed throughout our lives by these internalized authority figures and their beliefs. “It is useful to remember, says Coltart, that to fall below the standards of the ego ideal produces shame, and to fall below the standards of the superego produces guilt” (p. 257). In extending the origins of the superego to the pre-Oedipal phase, Melanie Klein (1933, 1937) views the emotion of guilt that begins with the earliest mother–infant relationship. In this primary and highly significant relationship, the child experiences intensely powerful emotions, the love of the mother, coupled with intense feelings of aggression towards her. Guilt appears as the child’s gradual awareness of the real and fantasized attacks on the mother, as the beginnings of the capacity for concern, the personal responsibility for the aggression towards the good object. Klein’s phase, the “depressive position” is actually a developmental milestone and a transition from feelings of guilt to feelings of responsibility. Explaining this as part of the normal developmental process, Winnicott (1958) attributes the feeling of guilt to the complicated psychic task of having to carry two contradictory emotions simultaneously. Conflicts and doubts accelerate the awakening of guilt feelings. Guilt may sometimes be identified with regret and with conscience. For example, Coltart (1992) discusses the connection between the concepts of guilt and conscience. She writes that conscience is the force that steers our consciousness and functions as a mechanism of directing and protecting. According to her view, most religious systems are built on standards of conscience, and it is the failure to live up to our conscience that arouses feelings of guilt. The philosophy of Heidegger informs Stolorow’s (2011) position, that our authentic existence includes existential guilt, the “voice of conscience.” It is an existential responsibility, which demands an accounting regarding the relations between one person and another. Thus we may conclude that guilt is produced by the conscience, and it can be closely related to a dominant religious perception. The bearing of responsibility arouses the conscience, while the failure to obey our conscience stimulate regret and guilt. Martin Buber (1957, 1965), who wrote extensively about Jewish consciousness, distinguishes between guilt feelings, which are attributed to the external world and deal with interpersonal relations, and guilt, which arises from the internal world. In his view, the psychotherapist is required to relate

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not only to those guilt feelings arising from the internal world of the superego, but also to the guilt that exists as an independent entity in the external world, namely between one person and another. In legal and judicial language, guilt may be seen in two ways—from the legal-judicial aspect, and from the moral one. Legal or judicial guilt is the type considered by the court in cases of criminal acts. If we relate to the observing of the Jewish religious commandments as a legal and existential imperative, then one aspect of the feeling of guilt may indeed be legal, that is a halachic prohibition. (Halachic—the Hebrew word for “according to the Halacha” namely the obligation to scrupulously observe the commandments of the Torah in all aspects of life.) The fine line between the legal and the moral aspects of guilt is originally described by Emanuel Levinas in 1961 (in Levy, 1997), 1985 and 2010, specifically the idea of the moral significance of one individual being responsible for another. This concept is based on legal aspects and also on the laws of the Torah. These obligate a person in his relations with others, together with the moral and conscience-based aspect, which is above and beyond all laws. It is an internal morality, which resides and arises within the mind, not necessarily in a Halachic or legal context but rather in a personal sensitivity-responsibility towards the other. We may infer from this that moral guilt does not depend on a particular act or deed. In Jewish thought guilt is an integral concept, which also has a positive dimension. A Jew is required to stop, to think and to examine his actions and his deeds. Levinas (1937 [in Hansel, 2007]) describes this well (in free translation from the Hebrew): “Halacha frequently indicates the need for a moment of reflection, thus creating a momentary pause in the flow of everyday life, which normally provides a permanent connection to things. An observant Jew does not take the world for granted.” The orthodox Jewish religious-educational approach encourages individuals to be aware of their acts, to reflect on them and to feel regret when appropriate. This approach, which intensifies the feelings of guilt by force of religious-educational training and habit, leads to greater complexity within the therapeutic process. We are dealing with a type of guilt that is both legal and moral, a product of the conscience as well as the superego. The feelings of guilt are often are not conscious emotions and are not revealed easily. Consequently it may appear in a wide range of situations and behaviors where its presence can only be seen with the help of a therapeutic process. Guilt feelings may appear in the form of different mental states, or they may be expressed through various physical sensations. These feelings may sometimes appear as their opposites in a “positive” way with the use of expressions such as “beautiful/good/clean” and so forth, or by exaggerated expressions of gratitude or the giving of excessive gifts. These acts may be

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used to counter feelings of guilt, for example in a situation where a person feels that he/she is not deserving of love, or feels guilty about repressed anger. Also, guilt generally creates a great sense of discomfort. In everyday life we may encounter it as a sense of helplessness, a feeling of regret, the fear of an approaching disaster, an ongoing sense of suffering or sometimes as a compulsive need for cleanliness (Freud, 1907). We may infer that the feeling of guilt is frequently hidden and protected, serving defensive purposes. However, this feeling also carries the potential for healing, and it may enable a positive process of repair. GUILT IN THE CLINICAL SETTING

It appears that the need to observe the commandments and the belonging to the orthodox Jewish community that demands high levels of observance increases the sense of guilt and the frequency with which it is encountered. When guilt surfaces during the therapeutic process, it restricts the therapeutic space, obstructs the reaching of insight and may sometimes it can even sabotage the entire process. By the way, the clinician is no exception, and I will later describe the presence of guilt in my own internal processes as I participate in the therapeutic work. I believe there are three main areas where guilt plays a central role for members of this community who come to psychotherapy: guilt created by the very fact of being in therapy, guilt related to speaking and thinking about forbidden topics, and guilt because of a decrease or “deterioration” in spiritual or religious belief or activity. Guilt about being in therapy

Judaism teaches that a person should continually strive towards higher moral and ethical standards. For an orthodox Jew, the primary obligation is to develop and enrich his spiritual self, and one of the ways to attain this goal is by showing concern for the other. Too much concern with one’s own personal needs is regarded as unacceptable and rather selfish behavior, an unnecessary indulgence or luxury. The decision to come to therapy may be understood by the patient himself, or by his close family and friends, as a failure of attempts to find solutions to one’s personal problems through religion—solutions such as prayer, receiving the blessing of a rabbi and strengthening one’s spiritual life. These feelings of failure continue to exist and they lower the patient’s self-esteem, already damaged, and add to a strong sense of lack of faith. In recent years we have seen a broader understanding of the need for psychological treatment. Nevertheless, the Halacha and the social and

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community norms still have a major influence on the religious perception of the individual and they play a part in the awakening of guilt feelings (Meissner, 1996). The rabbi plays a significant part in the life of each person, and his role includes giving permission for going to therapy. The rabbi grants permission but is generally not an active participant in the therapeutic process. A Haredi person turns to his rabbi in order to receive instructions or to seek advice. It is less common to share one’s personal feelings with the rabbi. Indeed, many rabbis today recognize the need for treatment of emotional issues, although they will more readily refer people to psychiatric treatment than to psychotherapy. Greenberg and Witztum (2001) have written about psychiatric treatment in the Haredi community, while Cohen and Gereboff (2004) have written in a more pluralistic vein about the meeting between psychoanalysis and Judaism. Lack of flexibility, an internalized rigidity, which became a structural part of the patient’s personality (Meissner, 1996), creates a sense of guilt. This holds true even in cases where the rabbi instructed the particular person to come to psychotherapy. In the course of therapy, a person learns to think, to observe himself and his surroundings, to understand his own ways of thinking, his desires and aspirations. This process leads to knowledge that is sometimes painful and not always wanted. As it is written in the Book of Ecclesiastes 1:18: “For in much wisdom is much grief: and he that increaseth knowledge increaseth sorrow” (in Hebrew: Yosif da’at, yosif mach’ov). For knowing means no longer being innocent, and this contradicts the verse from the Book of Deuteronomy 18:13: “Thou shalt be perfect with the Lord thy G-d” (in Hebrew: Tamim tiheyeh im Hashem Elokeha) (Hess, 2011a). In addition, the therapeutic process will bring about moments where the patient stops and asks himself: “Am I acting against the Halacha or a specific command? Do the changes that occur during therapy go against the Halacha?” These moments will be loaded with doubts, stopping, hesitation and self-examination. Topics that are related to drives will undoubtedly be accompanied by anxiety, fear of thinking about them and even more of speaking about them (Hess, 2007). The psychodynamic therapeutic framework allows and even encourages a person to take time and space for himself. The patient finds himself within his own individuality, fully immersed in his own world, spending long hours in conversation and in thought, while someone is listening to him and he is listening to himself. In the orthodox Jewish community, this situation arouses difficult questions: “How can I permit myself to be in this space just for and by myself? Isn’t this a luxury? Am I permitted to do this?” Even adolescents or young single men and women will ask these questions, while those who are parents face additional issues: “As a parent whose children

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need me around as much as possible and also need my financial support, am I allowed to spend time and money on talking about myself?” For example, Ilana, is struggling to functioning as a mother and raising her several children. Ilana is attached to her own mother in a symbiotic relationship, where she is denied the opportunity for emotional growth and maturing. Currently she is experiencing digestive problems for which no objective medical explanation has been found. She became a mother at a very young age, when she had not yet found herself. She feels herself to be an extension of her mother and has not developed a mature self of her own, which would enable her to function as a mother. During the 3 years of her treatment, the topic of payment recurred constantly. She returned to it every time she had to pay for her sessions and she organized the payment in an unusual way. She divided the amount into small sums and gave each one to me accompanied by an aggressive comment. This topic came up frequently in our sessions, where we discussed her childlike need to receive, and her feeling that she deserved to get everything without having to make any effort. Unusually for her, Ilana arrived empty-handed at one of our meetings. She said: “It was great to leave the house just as I am, as if I’m going out walking or to visit a friend … the only difference is that here it costs money.” Later in the session she again referred angrily to the amounts she had paid during the years of treatment: “Even if I finish the treatment and I’m satisfied, I will never forgive myself for the huge amount of money that I paid. I’ll feel bad about it for the rest of my life.” Ilana has difficulties in taking mature responsibility for herself. She is in a regressive position where she feels that everything should be handed to her on a plate. During the treatment she developed self-awareness and greater maturity. At the same time, however, along with the feeling of responsibility came the sense of guilt. As mentioned above, Ilana has recently been suffering from digestive disorders for which no physiological explanation has been found. She finds it difficult “to digest” unbearable feelings of guilt, and these “indigestible feelings” are unconsciously excreted through the body. She adds that this feeling cannot be calmed down, and that she has felt this way since the beginning of the treatment. She feels that her conscience is bothering her and this guilt is persecuting her. She feels guilty about the improvement in her general way of feeling, as if feeling well is a kind of indulgence. Being a depressed, suffering woman is more acceptable, a more familiar pattern—this was also how her mother lived and still lives today. Ilana even regards this way of living as one that is rooted in the Jewish-Haredi tradition, which demands a very simple, modest and even ascetic way of life. Feeling well, progressing, growing and developing arouse tremendous feelings of guilt in her. Undoubtedly there are feelings of unexpressed anger

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and envy hidden behind this sense of guilt—anger at the realities of the past and the present. Envy of what she wants (in her fantasies), of what she does not have, while others do. This envy may also be directed at the therapist, while the patient herself ostensibly neither needs nor deserves these things. Needless to say, the anger and envy cannot be expressed in the outside world, but only in the clinical setting. The encounter with difficult emotions such as envy, frustration, fantasy and anger leads to the creation of defense mechanisms—defense against the fear of knowing, of being in contact with these feelings and taking mature responsibility for them. In such cases the defense is expressed through the emotion of guilt. Stephen Mitchell (2000) differentiates between pathos and guilt on the one hand, and self-pity and “guiltiness” on the other. In his view, it is hard to carry the feeling of guilt. We do so while suffering silently, as we go on with our lives and try to draw some lessons from the events. Guilt is accompanied by sadness, pain and regret, but these feelings nevertheless allow us to move on to new possibilities. However, when a person feels that he is a victim and acts out his guilt, then the guilt functions as a defense and leads him to shut himself off from change and renewal. Guilt about forbidden speech and forbidden thoughts

Judaism forbids gossip and slander, as it is written in Leviticus “You shall not go about as a talebearer among your people” (Leviticus 19:16). The prohibition against gossip and slander is thoroughly learned and very wellknown at all levels of the Haredi community. In general, belonging to a specific community, be it a religious or any other close-knit group, obliges all members of that community to be loyal to the group and not to take personal matters or “gossip” outside. Specifically, a religious Jew is bound by the Halacha relating to gossip and slander. Speaking about others is not only immoral; it is a transgression that carries a punishment. This is one of the first questions, which a new patient asks at the beginning of his or her treatment: “How can I speak freely about everything and everyone that is bothering me in the light of this prohibition?” This question actually has a clear Halachic answer. One may speak about anything disturbing to someone with whom one has a close relationship, as it is written in the book of Proverbs: “Anxiety in the heart of man causes depression, but a good word makes it glad” (Proverbs 12:25). Speech is the verification of thought. The verbalization of that which is thought gives it existence and meaning. We know, however, that thoughts are a personal possession and we cannot enter the thoughts of another unless they are willing to share them with us. Patients who come from a Haredi background have been educated to accept everything as it is written, spoken

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or commanded without further comment or question. Therapy, however, creates a space where thinking is enabled and encouraged and when the Haredi patient becomes aware of this, he is likely to become anxious and withdraws. These patients frequently express fears and reservations, which refer both to their inner, private speech and to their fear of thinking. Shani, a woman in her forties who is now in her third year of treatment, came to therapy because of feelings of loneliness and emotional stress. She immigrated to Israel alone from a Western country, after the loss of her parents, in order to marry a young man by means of an “arranged marriage” (a shidduch in Hebrew). Her extended family remained in her home country. Shani and her husband have several children. Shani successfully runs her own business, meets women and creates contacts and acquaintances through her work, although these connections are rather distant and superficial. Despite having adolescent children and a busy working life, she feels that she has no one close to her and nobody to share things with. “In the past, I used to think that I was weird,” she often said. Her marriage is not a happy one. Her husband is a successful businessman, but selfish and insensitive and given to violent outbursts of anger against her and the children. Shani often finds herself in a crisis situation and is intensively considering divorce. However, she is reluctant to separate from her husband because of the children and her desire to hold the family together. She is also concerned about what people will say and about possible problems for her children when they reach a marriageable age. During the second year of her treatment, Shani spoke about her distress, about her husband’s lack of understanding and sensitivity and about the fact that he is as dependent on her as a small child and is incapable of providing support. Following another outburst of his one evening, Shani arrived at her next session very upset. She spoke very emotionally about what happened at her home the previous day, and about her husband’s uncontrollable anger. One could hear a deep despair in her voice. The conversation made her feel better and she ended the session with a feeling of relief, but at the next meeting she arrived confused and angry and even spoke about the idea of ending her therapy. I talk about my husband all the time, nothing changes, everything stays the same … I don’t think it’s right for me this way. I need a more optimistic outlook, so that I will be able to see the good side of things, and I won’t allow myself to be so spoilt … after all, when I look around, I see that everyone has their own problems. So actually, I’m just spoilt!! If I decide to really take myself in hand, it won’t be the end of the world—things will just get better … I have to take this upon myself …

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Shani’s words reflect the depressive position, the recognition and the knowledge of that which exists, what Bion calls K+, which is “emotional knowledge” (Bion, 1962). When knowledge (K) arises, there is a forced acceptance of reality from a developing place. The patient acknowledges the situation as it is and is prepared to confront it. She succeeds in “suffering the emotion,” but this is immediately followed by the fear of feeling—“anti emotion.” She then tries to “twist” her thinking, as well as that of the therapist, because the thought process becomes impossible. There is an emotional blockage created by the threatening truth. The feelings and her speaking about those feelings serve to confirm her intolerable position. These are thoughts, which are difficult to think, and which become even more powerful once they are spoken out loud, whereas the knowledge, or the declaration, that “I am not OK” is a controllable and manageable expression of a thought. It is a rationalization, which fits into the framework of her faith, where constant change and self-improvement are demanded. The insights gained as a consequence of speaking about these matters are frightening and create a heavy sense of guilt followed by fear. Speaking brings her into contact with her aggressive thoughts and then guilt arises because she is admitting these thoughts and speaks about them, as if these thoughts have brought [the situation] into being. Speaking creates the presence of the experience, and then denial is no longer possible. The aggressive expression of guilt is expressed here towards the “attacks on linking” (Bion, 1959) and by directing the aggression towards herself. Speaking about ending the therapy, despite the support it provides, is an attack on the links that have now become threatening. Guilt about spiritual “deterioration”

(a) Lior is a young man in his twenties. He is still unmarried (within the Haredi community, this is highly unusual and problematic for a man in this age group). He studies in a Yeshiva (center for advanced study of Torah) and lives at home with his parents. He was referred to treatment because of a suicide attempt. During the treatment it became clear that his existential position had become intolerable because of his parents’ demands for an extremely religious, ultra-orthodox way of life. Lior had been exposed to a more normative life among the students at the Yeshiva and while visiting their homes. Thus, as he matured and gained insight he began to identify the pathologies within his own family and realized that he had been living his whole life in an ongoing conflict, which could not be expressed openly. During the first years of treatment, after some initial improvement had been achieved and the threat of suicide had receded, the very existence of the therapeutic space and his great need for it created a major conflict.

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He struggled with his inner truth, his true self-expression on the one hand and the parental voices, both internal and external, on the other. His parents’ opinions were already internalized, and their voice was also his voice. Here are some quotes from this period of the therapy: I haven’t been to one of Rabbi A’s lessons for a long time, I’m not really interested in them … But I don’t feel good about that … I study on my own or go out for a walk and I feel almost as if I’m a criminal! I feel so bad about coming here when I’m supposed to be sitting in a lesson on morality and ethics! My parents complain all the time that since I’ve started coming to therapy, I’ve become less “frum.” (religious, orthodox). I told my parents that it’s difficult for them to listen to a viewpoint that’s different from their own. They replied angrily: ‘You bought that idea for money!’ Of course they were referring to you and to the therapy …

The feelings of guilt experienced by this patient stem from a persecutory and depressive conflict and a splitting of the soul that are almost impossible to resolve. The superego of prohibitions and the parental figures, the pathological mourning for that which does not exist, for that which exists in fantasy but does not become reality, for that which is desired but not accessible—all these conflicting elements cannot be digested or integrated at this stage. There is no doubt in Lior’s mind and in the minds of those around him that the therapy has benefited him greatly. But how can he live in peace with something good that is also so destructive for him? (b) Tamar, a highly intelligent and creative woman in her thirties, came to therapy following difficulties in her marriage. The couple has no children and they are undergoing a series of stressful fertility treatments. We discuss how her needs and drives conflict with what is permitted by Halacha and by the particular Hasidic group to which she belongs. Tamar gradually comes to the understanding that this conflict is inevitable as long as her belonging to this community is important and not open to compromise. After a year of treatment, Tamar said: Sometimes I ask myself what I’m doing here … how will all these conversations help me … everyone is living their lives quietly, Hasidic in every way, they feel good about it and they have no worries … . I walk out of here and it could happen that I would move away from a Hasidic way of life … that’s out of the question. I think it [the therapy] is just destroying all my innocence …

Here we see the fear of destabilizing the existing order, a well-known and universal fear. In this case, however, there is a subtle difference: it is possible that the change will lead to a different kind of looking and thinking, which may in turn bring about the risk of distancing herself or even—Heaven forbid—leaving her very orthodox way of life. Both her own personal doubts

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and her sense of communal-public responsibility create conflicts, which arouse guilt feelings. Here the patient finds herself in a paranoid-schizoid position (Klein, 1946). In teleological thinking, there are three possible uses for this position: self-expression and development, the prevention of development or the delay of such development. In Tamar’s case, the expression from the paranoidschizoid position prevents development because it does not allow her to remain in the therapeutic dyad without hearing the other voice, the voice of the community, the law, the Halacha or the customs (of orthodox Jewish life). The therapist and feelings of guilt

As a member of the Haredi community myself, I am familiar with these awakenings of conscience. Should I be “there” with the patient, and are these the patient’s guilt feelings or my own? I frequently end a session with a familiar feeling of guilt, my conscience pricking me and a well-known script of difficult and demanding inner questions running through my mind, accompanied by an inexplicable sense of anger. When the worlds of the therapist and the patient are close or even overlap, it becomes difficult to say where the feeling comes from and to whom it belongs. Understanding the counter-transference is always difficult but even more so when one is identified with the patient. Sometimes this creates a kind of certainty, as if to say “I know what you’re going through.” This response, however, should be handled with great caution because this feeling of certainty may dull or restrict the therapist’s ability to listen and observe. Even if it is very familiar, the ostensibly clear knowledge of how the patient experiences his orthodox way of life also has its roots in the counter-transference (Spero, 1981). In my experience, the most productive way to respond to this type of countertransference is to use the “potential space” (Winnicott, 1971) and to suggest a kind of playing together within this space, by saying something like: “Thinking about whether something is forbidden, permitted or right creates an annoying feeling of guilt within us … ” or “There’s a cloud of guilt floating around in this room which is preventing us from really looking at things …” Simply speaking about the pressures and the burden created by the superego can lead to a liberating space, and can enable us to gain a wider perspective. Or, as Bollas (1987) believes, empathizing and identifying with the patient’s distress provide a way of dealing with the counter-transference more easily. It is not possible to ignore, to bypass or to extinguish one’s conscience, but one can “become friendly” with it by means of a containing, understanding empathy. Nevertheless, it remains true that a Torah-observant, orthodox religious life leads to the active presence of an accusatory conscience.

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An observing and enabling therapeutic process can lead to a gradual softening of the superego, and consequently to a decrease of guilt feelings. However, this effect is often experienced by patients as a “spiritual deterioration” brought about by the therapy (research findings, Hess 2011b). This additional pain and burden of guilt feelings carried by orthodox-Haredi patients place great demands upon the therapist, who needs additional resources of creativity, patience, the ability to contain and to be in the “unknowing” (Bion, in Sandler, 2005). DISCUSSION

The short vignettes above illustrate the internalized religious experience as seen in each individual patient and based on their own personal inner dimensions, tendencies and emotional needs. The common denominator is the voice and the power of the superego—a bundle of parental, belief-based and religious internalizations. Each individual has their own personal logic in the development of guilt feelings. Kant (1781) reminds us that every human being has an inherent internal morality. Every person has understanding, which includes morality, and a person may choose which path to take. A religious person carries a tremendous number of conscience-based internalizations, the primary one being the presence of the all-knowing, all-seeing Creator. This ideal is expressed in the book of Psalms: “I have set the Lord always before me” (Psalms 16:8). This is followed by the moral internalization of parental authority. The tremendous influence and power wielded by parental figures in the course of human development is widely known. All psychoanalytic theories recognize the significant roles parents play in the formation of the self. The importance of the parents and the relationship to them is also reflected in the fourth commandment, “Honor your father and your mother.” Halacha demands obedience and submission to these figures, and explicitly commands us to respect them. And this is over and above the parental internalization that is part of normative development. Additional authority figures include various mythical characters such as Biblical figures, leading rabbinical figures and Torah scholars. Stories of miracles and of righteous men abound in children’s books, and these are added to the list of models whose behavior must be emulated and whose authority must be unquestioningly accepted. In everyday life, the orthodox person also encounters authoritative and influential educational figures such as teachers, rabbis, heads of Torah study institutions and others. So we may say that the superego incorporates imperatives from G-d, the command to obey and respect one’s parents and also the other authority figures mentioned above.

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From the very beginning of therapy, there is no space for a dyad. The “third” (Ogden, 1989) enters in the name of the Halacha or a rabbinical figure. It is not possible to enter into a prototype mother-infant situation, which will foster development, because from the outset there is a supreme authority present in the room. The presence of this “third,” in the form of the Halacha, a command or a rabbinical ruling, leads to judgmental thinking: acceptable or not acceptable. In this view (Bion, 1967), the meeting is a priori with “the known,” the existing and the accepted, with memory and with wants, as opposed to the therapeutic situation preferred by Bion, which should ideally be without memory and without desire. Religion, the need to observe the commandments and the fact that there are clear laws create a sense of guilt within the conscience. But guilt, as set in motion by the superego, is not necessarily related to a person’s level of religious faith. It is true, however, that a strict observance of the laws and requirements strengthen the superego, which becomes strict or even persecutory, thus creating feelings of distress, primarily guilt. Clearly the level of strictness of the superego depends on each individual’s specific personality traits as well as his or her cultural background and world of internalizations. Within the clinical setting, guilt may fulfill a number of functions. Sometimes it can serve as a defense. Dealing with troubling guilt feelings may protect the patient from exposure to other truths such as powerful drives or the longing for something forbidden by the Torah. This use of guilt as a defense follows Freud’s view of guilt as well as others, such as Coltart, if the longing or the drive are stronger than the conscience, they arouse guilt. In such cases, dealing with the feeling (of guilt) provides a defense against confronting the root cause of the feeling. To return to Mitchell’s (2000) ideas, “guiltiness” does not allow progress. It prevents us from moving forward and results in stagnation and anxiety. At other times guilt may appear as a symptom of self-punishment, with the aggression directed inwards towards the self, contact with the depressive position with knowledge and internalized aggression. The discovery and the knowledge can be understood according to Bion’s concept of K+ (1962), that the recognition and the exposure of the knowledge lead to frustration and aggression, and when these cannot be expressed, they are turned inwards. In such cases there is also guilt over disguised aggression (Klein, 1957). Guilt as a symptom of self-punishment may be expressed as an “attack on linking” (Bion, 1959) and the threat of ending therapy, as illustrated in the case of Shani described above. We may also find guilt as a form of coping with an impossible situation, with conflict or with emotional states of instability in one’s religious identification, a pulling in both directions, or trying “to have one’s cake and eat it” at the same time—maintaining a strict observance of the commandments and

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also doing what the heart desires. This is a Winnicottian (1958) type of guilt, in which feelings of guilt are related to the inability to handle conflicting emotions simultaneously. In his view, this is a developmental milestone and a transition from a feeling of guilt to a sense of responsibility. Winnicott explains that doubts and conflicts accelerate the awakening of guilt feelings. Seen from this viewpoint, we can be more optimistic regarding guilt and we can expect development towards integration. In this article I have attempted to describe and discuss an issue that I frequently encounter in my clinical work. It is my hope that the opening up of the topic of guilt feelings will encourage further thinking and development of this dilemma—one of the many that we face in our difficult but valuable work.

REFERENCES Bion, W. (1959). Attacks on linking. International Journal of Psychoanalysis, 40, 308–315. Bion, W. (1962). Learning from experience. London: William Heineman Medical Books. Bion, W. (1967). Notes of memory and desire. The Psychoanalytic Forum, 2(3), 272–273, 279–280. Los Angeles, CA: Psychiatric Research Foundation. Bollas, C. (1987). The shadow of the object. London: Free Association Books Ltd [Hebrew-language edition, Tel Aviv, Dvir Publishers, 2000]. Buber, M. (1957). Guilt and guilt feelings. Psychiatry, 20(2), 114–129. Buber, M. (1965). The image of man: Studies in philosophical anthropology (philosophical writings, Vol 2) Hebrew-language edition Jerusalem: The Bialik Institute 1965 (second edition). Cohen, M. & Gereboff, J. (2004). Orthodox Judaism and psychoanalysis: Toward dialogue and reconciliation. Journal of the American Academy of Psychoanalysis, 32(2), 267–286. Coltart, N. (1992). The super-ego, anxiety and guilt. Free Associations, 3(2), 243–259. Freud, S. (1907). Obsessive actions and religious practice. Standard Edition (Vol. 9, pp. 115–128). London: Hogarth. Freud, S. (1923). The ego and the id. Standard Edition (Vol. 19, pp. 3–68). London: Hogarth. Greenberg, D. & Witztum, E. (2001). Sanity and sanctity: Mental health work among the ultra-orthodox in Jerusalem. New Haven, CT: Yale University Press. Hansel, J. (2007). Levinas in Jerusalem. Psychological interpretation and religious perspective. Jerusalem: Magnes Press. Hess, E. (2007). Being a Haredi patient. In Issues in psychology, psychotherapy and Judaism (pp. 105–121). Jerusalem: Nefesh Israel Publication. Hess, E. (2011a). On the knowing. http://www.psygroups.com/iapp/. Hess, E. (2011b). Psychoanalytical psychotherapy in the ultra-orthodox community: Contradiction, Conflict or possible tension. Ph.D. Thesis, Alexandru Ioan Cuza University, Iasi, Romania.

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Kant, I. (1781). Critique of pure reason. Translated into Hebrew by Yovel, Yirmiyahu. Sifriyat Hapoalim Hakibbutz Hameuhad 2013. Klein, M. (1933). The early development of conscience in the child. In R. E. Money-Kyrle (Ed.), Love, guilt and reparation and other works 1921–1945 (Vol. I, pp. 248–257). New York: Free Press 1975. Klein, M. (1937). Love, guilt and reparation. In R. E. Money-Kyrle (Ed.), Love, guilt and reparation and other works 1921–1945 (Vol. I, pp. 306–343). New York: Free Press 1975. Klein, M. (1946). Notes on some schizoid mechanisms. International Journal of Psychoanalysis, 27(3), 99–109. Klein, M. (1957). Envy and gratitude. In R. E. Money-Kyrle (Ed.), Envy and gratitude and other works 1946–1963 (Vol. III, pp. 176–235). New York: Free Press 1975. Laplanche, J. & Pontalis, J.-B. (1973). The language of psychoanalysis. D. NicholsonSmith (Trans.). New York: W. W. Norton. Levinas, E. (1985). Ethics and infinity: conversations with Philippe Nemo. Pittsburgh, PA: Duquesne University Press. Levinas, E. (2010). Totality and infinity: An essay on exteriority. Jerusalem: Magnes Press. Levy, Z. (1997). Otherness and responsibility: A study of Emmanuel Levinas’ philosophy. Jerusalem: Magnes Press. Meissner, W. W. (1996). The pathology of beliefs and the beliefs of pathology. In E. P. Shafranske (Ed.) Religion and the clinical practice of psychology (pp. 241–267). Washington, DC: American Psychological Association. Mitchell, S. A. (2000). You’ve got to suffer if you want to sing the blues: Psychoanalytic reflections on guilt and self pity. Psychoanalytic Dialogues, 10(5), 713–773. Ogden, T. H. (1989). The primitive edge of experience. Tel Aviv: Am Oved [Hebrewlanguage version]. Sandler, P. C. (2005). A dictionary of concepts. London: Karnac Books. Spero, M. H. (1981). Countertransference in religious therapists of religious patients. American Journal of Psychotherapy, 35(4), 565–575. Stolorow, R. D. (2011). Toward greater authenticity: From shame to existential guilt, anxiety, and grief. International Journal of Psychoanalytic Self Psychology, 6(2), 285–287. Winnicott, D. W. (1958). Psychoanalysis and the sense of guilt. In J. D. Sutherland (Ed.) Psychoanalysis and contemporary thought. London: Maresfield Library. Winnicott, D. W. (1971). Playing and reality. London: Penguin Books.

BIBLICAL REFERENCES All quotations from the Bible are from the New King James Version. “Scripture taken from the New King James Version®. Copyright © 1982 by Thomas Nelson, Inc. Used by permission. All rights reserved”. Genesis, Exodus, Leviticus, Deuteronomy, Ecclesiastes, Proverbs and Psalms.

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