The scarf is tied tightly around my eyes. I grope and stumble in the dark, looking for my Ima. Eventually, I catch hold of a figure. I rip the scarf from my face. But it is never Ima. It’s always one of her three faces.

Blind Man’s Buff was the game we unanimously favored throughout our childhood. When Ima was busy and Abba out, we’d escape quietly into the playroom. We drew the curtains, making sure that not a drop of sunlight could peep through.

Then the argument would be on. Who starts? Not wanting to waste too much time, some unfortunate would reluctantly agree to be ‘It.’ As the oldest, I had the honor of tying a black scarf around the scapegoat’s eyes, religiously checking that there could be no cheating. The door was shut, and the chase was on.

Dodging groping hands, we hid behind the couches, tables, and chairs, emitting occasional growls and squeaks to lure the pursuer even closer. We’d even change the set-up of the room, placing obstacles in the center. More often than not, we would trip over them (the black scarf an unnecessary prop in the pitch-dark room). Eventually, a victorious shout would be heard: “I got you!”

The subsequent identification procedure was merely for bureaucratic purposes (to lengthen the game), and then the scarf changed eyes and we started again.

As time passed, we added excitement to the game, even changing clothes to prevent eventual recognition. There were one or two occasions when Pursuer was unable to identify his catch. The scarf would be lifted from his eyes and the door opened. ‘It’ usually ended up staring in disbelief at a figure attired in at least one article of clothing belonging to every other member of the family, amid shrieks of our laughter.

A long time has passed since then, but mention of this game will always elicit a smile.

There’s another game of Blind Man’s Buff that I played… and haven’t stopped playing. I play it with my mother.

The scarf is tied tightly around my eyes. I grope and stumble in the dark, looking for my Ima. Eventually, I catch hold of a figure. I rip the scarf from my face. But it is never Ima. It’s always one of her three faces.

Unlike Eve in The Three Faces of Eve, Ima had one face for a few years, switched to another one for another couple of years, and now wears her third one.

As a child, I never wore a scarf. I was too young to realize that my mother was different from others. I grew older, and I didn’t like what I saw. I tied the scarf round my eyes. The search was on.

After a while, I thought I had caught my Ima. I let the scarf drop, only to find her most terrifying face. It was one of pinching, slapping, and yelling. It was one of name-calling and false accusations. It was one of food deprivation for miscreants. I pulled the scarf back over my eyes quickly. That wasn’t, couldn’t be, my Ima.

A number of years passed. I suffered from bruised shins and aching knees as I blundered in the dark, searching for Ima.

A change in medication led me to believe that I had found my Ima. More cautiously than the first time, frightened of what I might find, I slowly pulled the scarf down to behold Ima’s second face.

Less frightening than before, though no less bewildering, this face was a child’s face. It wept and sobbed, wailed and moaned, decrying its terrible fate in life. This was my Ima? A crying infant who did not even try to function as a mother? Not mine! I retreated once again behind the familiar, though stifling scarf.

Could anybody ever encourage me to remove the scarf again? But I had grown older, wiser, more prepared in the last five years or so. Should I try again? Persuaded, I painfully, tremblingly loosened the scarf, and let it hang around my neck. I pried open my eyes to meet the third face of Ima.

This was someone entirely new. Had I been younger, I may even have believed that this was my real Ima. But armed with that wisdom those years of tumbles and falls had afforded me, I knew it was not my Ima. This was a stranger — a polite, new addition to our household. She asked me how my day went, inquired about my exam, wondered if I found a job. She functioned in her household duties fairly well; she only had strange attacks several times a week. She forgot what you told her from one minute to the next and did not understand humor or sarcasm.

She has kept this face for the longest period of time so far, going on 15 years.

I’m married now, and we live far apart. We speak sporadically, exchanging comments on the weather or my newest recipe. And that’s it. She knows my name, and that I happen to be her daughter, but she doesn’t know what makes me tick, what I like, or what hurts me.

Ima doesn’t read the papers or know who’s president, and she doesn’t even realize that she’s only half living in this world.I still wear my scarf. It’s not so tight now, nor so suffocating. But it’s uncomfortable and still causes me to trip, stumble, and fall. I have accumulated many scars over the years, mostly ones that refuse to heal.

I have adapted to the game somewhat, anticipating a move in the furniture and cleverly skirting the obstacles. But….

I’m waiting for the day when this game will come to an end. I’ll grasp a figure passing by, and instead of running away, it will gently remove my tattered scarf, soaked in tears. Its arms will come around me in a warm embrace. The door will be flung open, and in the sudden, dazzling light I’ll see my real Ima.

(Originally featured in Family First, Issue 625)

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 “The frum community isn’t immune to clinical depression panic and anxiety disorders bi-polar disorders and the like.” MHMC’s $20 million facility will provide a safe environment for those in need of hospitalization (Photos: Lior Mizrachi)

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“Too many times I’ve seen children who have suffered for years living with a depressed parent ignorant of what was going on confused and frightened ” says London-based psychotherapist Rabbi Yaakov Barr MSc PGDip who specializes in treating severe depression

The post Depression in the Family first appeared on Mishpacha Magazine.

S

he’s the high schooler who always says yes, chooses chesed over sleep, and pretends things don’t bother her when they really do. She’s that girl in shidduchim who predicts her date’s reactions and strives to be whoever he wants her to be. The ever-apologetic employee who always stays late, piling ever more responsibility onto her already-full plate… the wife who offers to babysit everyone else’s kids, although she hates the chaos… the woman who never turns down Shabbos guests, even at the expense of her family.

Maybe you know her. Maybe she’s you.“She’s sooo nice,” everyone raves.

Which is precisely the problem.

Because she’s codependent.

What is Codependency?

The term “codependent” was coined in the 1980s to describe a person close to an alcoholic — often the spouse, parent, or child — whose life had become unmanageable due to constantly trying to “fix” the addict’s behaviors. This relative often fell into the role of caretaker, neglecting himself to constantly be there for the alcoholic. While the addict was dependent on the substance, the family member was dependent on the addict.

However, psychology leaders soon began identifying elements of codependency — low self-esteem, a need to nurture others, etc. — in families unmarred by addiction. These patterns emerged in relationships with individuals who were emotionally unhealthy, irresponsible, or immature, or who struggled with chronic illness or compulsive behavior. They began to apply the term “codependency” to these situations as well.

By 1992, Melody Beattie’s classic treatise Codependent No More defined a codependent person as “one who has let another person’s behavior affect him or her, and who is obsessed with controlling that person’s behavior.” Codependents, researchers found, were often people pleasers and over-givers, always ready to “save” someone. Because they invest so much into managing relationships, they often demonstrate a lack of relationship with one’s self. Usually benevolent and perceptive, they often anticipate others’ needs, but have difficulty asserting their own needs or wants. They intrude into other people’s business (for their own good, of course!) and thrive on nurturing relationships at their own expense.

One key feature of codependency is that self-worth is contingent on other people’s perceptions, explains Pia Mellody, author of Facing Codependence, rather than coming from within oneself. (To test your self-esteem, ask yourself, “Would I accept and respect myself if this person wasn’t there, or if this person didn’t like me?” If not, you have what Mellody dubs “other-esteem” — esteem dependent on external factors.)

The Seeds of Codependence

Codependent patterns and behaviors typically take root early in a person’s life.

Expert Pia Mellody explains that children who receive “less than nurturing,” shaming, or traumatic experiences from parents (whether intentional or not) learn dysfunctional survival traits that form the core symptoms of adult codependence.

What does “less than nurturing” parenting involve?

Mellody theorizes that children have five natural characteristics: They are valuable, vulnerable, imperfect, dependent (needing/wanting), and immature. Parenting that’s dysfunctional, “less than nurturing,” or abusive does not let children experience these very healthy characteristics, and the children subsequently become unbalanced in their emotional development in these key areas. For example, children forced to be “little adults” too early learn that they’re either “good/perfect” or “bad/rebellious,” and grow up to become either perfectionists or rebels — and then codependents.
Codependents aren’t always needy and clingy, adds Mellody. They may go to the opposite extreme, demonstrating superiority, perfectionism, overmaturity, and antidependence. “Though they may seem well-adjusted, their pain from unfulfilling relationships, dissatisfying careers, and depression indicates the opposite,” she writes.

In her many years of marriage and family therapy, Teaneck psychotherapist Dr. Rachel Sarna has come across both the product and the cause of codependency — the codependent parent who plants the seeds for the next generation of codependent adults. Sarna points out that overindulgent parents are just as likely to foster codependency in their children as critical or neglectful parents. It’s easy to see how codependency stems from the latter: the child who’s constantly rebuked feels he doesn’t meet his parents’ expectations. He can’t do anything right, he is told — and he learns to believe it. This child, adds Dr. Sarna, will always feel inadequate, becoming a codependent adult who perpetually seeks validation. Oftentimes these codependent adults are very sensitive: If a spouse or friend gets upset for any reason, they’ll automatically assume it’s because of them.

Pia Mellody — a recovered codependent, like many codependency experts — offers a personal example: As a newlywed, she immediately thought her husband wanted a divorce the first time he asked her not to wash his coffee cup before he finished drinking the coffee.

But what about the overindulgent parent who gives the child anything he wants — toys, time, etc. — without enforcing disciplinary boundaries like bedtime, rules, or manners, because she’s afraid that “No” will turn the child against her? “She gets upset if the other parent wants to reinforce discipline,” says Dr. Sarna, “and makes him do it, if he insists. This can be a really wonderful mother — everyone loves her, she does it all. I call her the ‘kol yachol woman.’ But she has a problem: When the parent is so concerned about overprotecting the child, the child cannot build his own resilience.
“The overindulgent parent will do the child’s homework because she doesn’t want the child to work so hard or go to sleep too late. She thinks she’s showing the child love, but the subliminal message is that he can’t do difficult things by himself. So when he grows up, he doesn’t trust himself to write a good enough essay, prepare a simple meal, or buy a sweater on his own. This adult will constantly second-guess himself — he’ll depend on someone else to make decisions, and in marriage, will need constant validation from his spouse and will think life is unfair when others won’t cater to him as his parents did. These are all elements of codependency.”

How can parents strike the balance between giving too much — or too little? Dr. Sarna has her own take on the popular parenting mantra. “While you give them the roots, help them sprout wings. Grant them their needs while helping them develop tools to take care of their own needs in the future.”

Are Jews Too Giving?

Codependency runs on a continuum, asserts Dr. Sarna. “Each of us has a little bit of codependency inside. We all want to be needed, loved, and cared for.”

Rabbi Simcha Feuerman, LSCW-R, who serves as director of operations for Ohel Children’s Home and Family Services, and the president of Nefesh, the International Network of Orthodox Mental Health Professionals, concurs. “Just like we can all have a bit of paranoia at times, or sometimes behave compulsively, we can all be a little bit codependent, too.”

Some professionals believe 80 to 90 percent of people in Western society have “low-level” codependency. In fact, one research study (Prest, Benson, Protinsky, 1998) shows that the very traits that professionals identify as codependent in clinical populations are associated with favorable characteristics of family functioning in nonclinical populations.

How, then, can codependent behaviors be harmful? “What makes it unhealthy,” continues Dr. Sarna, “is the extreme. Are we so anti-dependent that we’re scared to ask for help? Are we compulsively codependent, where every little decision needs to be validated?”

Discovering codependence can be complicated in the frum community because many cultural values — vatranus, mesirus nefesh, lifnim mishuras hadin — seem like extreme levels of self-sacrifice.
Frum Jews are actually more prone to codependency, says Simcha Feuerman. “We have an ethos of chesed — we often don’t turn down anything — so it’s hard to realize when one is in a codependent relationship. It’s hard to draw the line between being an ‘enabler’ and doing chesed. It’s difficult to understand when withholding involvement is the right thing. And it’s harder for codependents to draw these boundaries, because they have an extreme need for approval.”

This, says Rabbi Feuerman, is a central challenge in dealing with frum codependency. “Many people believe giving is always the right thing, but Chazal have a lot to say about misplaced chesed,” he emphasizes. “For example, the foundational rabbinic statement about codependence is in Koheles Rabbah [7:16]: ‘Whoever is [inappropriately] merciful when he should be cruel will ultimately be cruel when he should be merciful.’ And Berachos 33a warns us not to ‘have mercy on a foolish person.’

“We see from here that there are limits. And when we have difficulty comprehending these limits, we may be suffering from codependency.”

But Rabbi Leib Kelemen — who founded an international network of self-help groups dedicated to character development — cautions against over-diagnosing codependency among frum people. The veteran author and educator maintains that context is vital to determining whether a behavior or relationship is unhealthy.

“Every situation is nuanced,” he says, warily. “People mean different things when they label behaviors as codependent, some of which are genuinely pathological, but some of which are perfectly healthy or even admirable. That’s why it’s important never to diagnose without knowing the story. Acts of extreme, outlandish giving in a friendship may be signs of codependence, whereas those same giving acts may be completely acceptable in a healthy, loving relationship between husband and wife.

“There’s nothing wrong with loving someone so much that the person becomes the focus of your life. That’s called ahavah,” he continues, citing the well-known tale of Rav Aryeh Levin who told the doctor, “My wife’s foot hurts us.” “There’s nothing wrong with letting go of what you want for the sake of someone else. That’s called chesed. There is, however, something unhealthy about enabling another person’s addiction, irresponsibility, or under-achievement, or needing a person’s approval more than Hashem’s.”

Los Angeles–based clinical psychologist Rabbi Dr. Dovid Fox, director of clinical interventions and community education for Project CHAI of Chai Lifeline, has another way to clarify the difference between healthy chesed and codependency.

“Codependents have an essentially good quality of wanting to please others, but they do so excessively. When someone becomes clingy and merges with another’s demands/whims, we call it codependency because they’ve submerged their own sense of self with that of the stronger or needier individual. The codependent has an underdeveloped and undefined sense of personal identity, and is driven to morph within whatever they attribute to that other person so as to somehow find worth, when in fact they have merely become a shadow of the person they’re helping.

“Even Chazal instruct us, ‘Bear the burden with another’ — nosei b’ol im chaveiro — which means: Lend assistance but don’t forget that you are still you, and he is still him,” continues Dr. Fox. “The Torah commands us, ‘Love your friend as yourself,’ which presupposes self-care, not self-abnegation.”

Unfortunately, says parenting expert Dr. Miriam Adahan, high schools and seminaries may indirectly encourage codependency by promoting the idea of giving 24/7, without boundaries.

“Women are expected to perform endless social obligations, while keeping a house spotless, making gourmet meals, working full-time, and being a good mother. Unrealistic demands are harmful to a person’s physical and emotional well-being,” she says. “In our attempt to make sure our children don’t become narcissistic and selfish, we sometimes go to the opposite extreme, making children give so much that they lose their sense of identity and their ability to make choices based on what’s best for them.”

Schools can unwittingly create codependent children, says Rabbi Dr. Benzion Twerski, who has been working with addicts and codependents for over 30 years. “Our yeshivos are failing significantly in providing the kind of education that covers emotional issues like boundaries, self-esteem, and managing healthy relationships. The deficiencies are staggering.

“Most frum Jews don’t think these emotional dysfunctions apply to them. But they do. There’s no shortage of frum people at 12-step meetings. And schools don’t want to discuss these things because they expect parents to. But parents have no idea that they need to — let alone how or when.”

Simcha Feuerman has some advice for parents, though: Use teachable moments — everyday opportunities to train kids on healthy giving. “For example, if your child’s classmate constantly asks for snacks, what will you tell your child to do? Where do your child’s needs end, and another’s begin? If you aren’t sure, ask a rav.”

This is critical, he states, because a child who has self-respect will be prevented from accepting abuse — of any kind.

“Although as frum Jews we have three foundational middos of sympathy, humility, and chesed, a younger person has a hard time distinguishing when to be a bayshan and when to tell the other person that something is unacceptable, which leads them to give consent to things they’re not comfortable with.

“We need to teach kids they don’t have to accept unacceptable behaviors, that being liked by someone else is not the goal — they can be wholesome without feeling attached to someone else.”
Mechaneches Mrs. Rivka Yudin ardently advocates this message. As a former high school teacher, women’s lecturer, longtime seminary teacher, and coordinator of a counseling line on dating, marriage, and shalom bayis, Mrs. Yudin has been raising awareness of codependency among her students and women from various backgrounds.

In her annual Yemei Iyun in various seminaries, she now spends an equal amount of time speaking about codependency among friends as she does on dating and marriage. “There’s not one person in the room who isn’t nodding her head,” she says. “Everyone knows someone involved in an unhealthy friendship.”

Noted educator Dina Schoonmaker says codependent friendships have elements similar to addictions: “the highs, the lows, the crashes, the quick fixes, and even sometimes the physical elements. When the boundaries aren’t there, and the relationship gets very intense, even the physical lines can get crossed.” Her litmus test? “In healthy relationships people choose to spend time with each other. In unhealthy relationships people need to be with each other.”

“There’s usually one friend displaying more neediness, but even the one who seems less needy and more confident, in fact, needs to be needed,” adds Mrs. Yudin.

“These codependent young women can get married and go on to lead normal lives, but sometimes they need therapy to identify why they engaged in the codependent relationship in the first place,” Mrs. Schoonmaker says.

But it’s not just friendships that are of concern. As director of NCSY Michlelet, a summer program in Israel for high school girls, Mrs. Rivka Yudin trains her madrichot — and students entering chinuch — on the importance of creating healthy boundaries.

“While the goal in chinuch is to care about, encourage, build up, and love our students/campers, the ultimate goal is to help each one stand on her own two feet. Sometimes a mentor thinks she’s helping the child by constantly being there, when in reality she may be creating an unhealthy codependency.”

Resolving Codependency

To the codependent, the source of his issues seems to be the “other” person. But, stresses Melody Beattie, “The heart of the definition and recovery [of codependency] lies not in the other person… It lies in ourselves — in the ways we’ve let other people’s behavior affect us and in the ways we try to affect them.” Which brings us to the first step of recovery: recognizing the core symptoms of codependency in ourselves.

“Recovery calls for a fundamental shift in one’s personality, attitude, coping mechanisms, and behavior in all interactions, even with yourself,” writes codependency expert Darlene Lancer. According to her, recovery involves developing one’s self-esteem (not other-esteem), learning to be realistic with oneself and others, and communicating assertively. In the process, the codependent works on making his own decisions, taking responsibility for mistakes without feeling deep shame, and practicing self-care, among other healthy behaviors.
None of this is easy. Confronting the consequences of codependency often causes pain and fear, but this is normal — and expected. The pain, says Lancer, is necessary to engage in successful recovery work.

Nor will progress be quick. “Codependent behaviors are deeply engrained… it takes patience, strength, and perseverance to unlearn and replace bad habits and attitudes,” she continues, which brings to mind the famous quote from Rav Yisrael Salanter that it takes a lifetime to change a middah.

According to Pia Mellody, as codependents work the recovery process, they start learning these healthy characteristics: Healthy people are able to esteem themselves from within to be intimate and vulnerable with protective boundaries; to be responsible for their self-care and to be interdependent; and are able to experience reality moderately as well as maintain a sense of spontaneity.
Several tools are available to treat codependency. Professionals advise combining the options for best results.

Support Groups

Codependents Anonymous (CoDA) meetings, modeled after AA meetings, are safe places to gain information, encouragement, validation, empowerment, and insight from others struggling with codependency. The only membership requirement is “a desire for healthy and loving relationships.” Similar to CoDA, Al-Anon groups are geared towards relatives and close friends of alcoholics or addicts. Visit CoDA.org to find a meeting in your area or learn more.

Reading

Well-researched self-help material can further one’s understanding of codependency and offer recovery tools. Rabbi Twerski recommends the following:

• Facing Codependence: What It Is, Where It Comes From, How It Sabotages Our Lives by Pia Mellody. (Several women interviewed for this article mentioned that this book has changed their lives.)
• Codependent No More: How to Stop Controlling Others and Start Caring for Yourself; The Language of Letting Go: Daily Meditations on Codependency; Stop Being Mean to Yourself — all by Melody Beattie.
• Codependency for Dummies by Darlene Lancer, MFT.
• Women Who Love Too Much: When You Keep Wishing and Hoping He’ll Change by Robin Norwood.

Therapy

Therapy uncovers the source of one’s codependent behaviors to allow one to work through them and move forward. Sometimes this means tracing codependency back to childhood; other times, says Dr. Fox, the past is less involved.

“For some low-level codependents, we’re helping them step away from their relationships, take a moment to reflect and ask, Who am I? And where are my daled amos? This is a somewhat shorter-term study of your bedrock, which will shift and solidify precisely because, for the first time, you identify the strata of identity which is self, and you examine its material.”

But Rabbi Dr. Benzion Twerksi advises people to certainly seek therapy if they suspect they’re involved in a serious codependent relationship. “Sometimes, one can reorganize the dynamics and patterns of the relationship through therapy by setting proper boundaries. Other times, however, the codependency has become too intense to split hairs between the person and the unhealthy behaviors. In these cases, one cannot extricate himself — we call this detaching with love — unless one completely breaks contact with the other party. This decision, though, can only be made with the help of psychologists and daas Torah.”

Dr. Fox mentions additional benefits of therapy. “Therapy can also help someone clarify the differences between healthy giving and codependency in the specifics of his life,” he says. “Clients get to know themselves with greater depth and clarity. Even with therapy, the recovering codependent may still tend to be the ‘giver,’ but he’ll recognize it within himself and reduce the conflict surrounding those situations. And he may discover that self-respect doesn’t hinge on what he does for others or what others think about him.”

Ultimately, therapy is more about self-awareness than about stopping codependents from doing nice things for others — although this certainly plays a role. When Shifra first started working on boundaries and self-care as part of her codependency recovery, she felt selfish as she refused inappropriate requests for her time and energy. But she slowly began to realize that she was simply being responsible for herself.

Recovery will always feel extreme to the codependent, says Pia Mellody, because he’s been entrenched in those patterns for so long. The process is like a seesaw — for years, the codependent weighed down one end. In recovery, he may take drastic measures and swing to the opposite extreme. But after some time, he’ll figure out a steady medium — that sweet spot between self and others, between chesed and limited boundaries, between control and letting go.

Remember, though: Life isn’t about dangling perfectly in midair in every situation. It’s about finding that balance more often than not. Moreover, part of recovery is realizing that recovery is not about perfection, it’s about progress.

Dr. Fox — echoing every other codependency expert — stresses how important it is for codependents to remember G-d (or, as the non-Jewish experts call it, the Higher Power), not just in their recovery process, but during their daily struggles. “The codependent wrongfully believes that they and only they can manage the situations in which they burrow themselves, and Hashem is sadly relegated to some nonexistent place in outer space. In recovery, the codependent needs to work on his faith, and realize that only Hashem determines outcomes. We shouldn’t err in believing that we can rely on our own efforts to make things happen. Having faith in Hashem is extremely important.”

And there’s hope at the end of the long road. “As difficult as it is,” says Dr. Sarna, “when codependents work on learning how to live without codependency, it gives them an amazing sense of freedom and relief.”

What does codependency look like?
Unsure whether you’re in a codependent relationship? Here are some examples of common codependent thought patterns, excerpted with permission from Codependents Anonymous.

• Denial patterns
  I minimize, alter, or deny how I truly feel. I perceive myself as completely unselfish and dedicated to the well-being of others.
  I express negativity or aggression in indirect and passive ways.

• Low Self-Esteem Patterns
  I value others’ approval of my thinking, feelings, and behavior over my own.
  I need to appear to be right in the eyes of others and will even lie to look good. I constantly seek recognition that I think I deserve.
  I have trouble setting healthy boundaries.

• Compliance Patterns
  I am extremely loyal, remaining in harmful situations too long.
  I compromise my own values and integrity to avoid rejection or anger.
  I am hyper-vigilant regarding the feelings of others and take on those feelings.

• Control Patterns
  I attempt to convince others what to think, do, or feel.
  I have to be needed in order to have a relationship with others.
  I adopt an attitude of indifference, helplessness, authority, or rage to manipulate outcomes.

• Avoidance Patterns
  I judge harshly what others think, say, or do.
  I suppress my feelings or needs to avoid feeling vulnerable.
  I pull people toward me, but when they get close, I push them away.

(Originally featured in Family First Issue 443)

Part 2: See codependency in action. Experts analyze scenarios of codependence.

Nechama H. Raphaelson is working on a book about frum codependency. She welcomes your thoughts, comments, and stories. She can be contacted confidentially through Mishpacha.

The post Too Close for Comfort first appeared on Mishpacha Magazine.

In Part One, we introduced the concept of codependency — a dynamic in which two people are dependent on each other in unhealthy ways. Here, we examine four common codependent relationships, see how they can become established, and explore what one can do to disentangle from the clutches of codependency.

The Addict’s Wife

I’m 35, and I’ve been married for ten years to an alcoholic. We have six children. For the first three years of marriage, I pleaded with him to change… and I was confident I would succeed.
As the eldest of ten, I knew how to keep things together. Even at work, I was always the one responsible for the efforts of all the employees. I often gave suggestions for better productivity to my boss, who quickly promoted me to manager. So I was optimistic about my marriage — I could fix this, just like I fixed everything else.

But I soon realized this wasn’t working with my husband.

He’s frequently drunk, more preoccupied with bars than with his family. All the housework, finances, cooking, and child rearing falls on me. I barely have time to sleep, get dressed, or even eat.
My husband, meanwhile, bounces back and forth between promises of change and excuses that he can’t. I give him second, third, and fourth chances. I stay up late, reheat his dinners, and call his boss to say he’s sick when he’s too hungover to work. (If he loses his job, how will we pay our bills?) I make excuses at family gatherings when he doesn’t show up.

I used to be extremely sympathetic. I kept a calm demeanor, invited guests for Shabbos, and swallowed my anger and sadness. But my resentment is becoming overwhelming, as my entire life revolves around taking care of my husband. I’m angry at him for never being there, for making me work so hard, for giving me nothing when I do so much for him. It kills me when my children see my husband’s passed-out body in the kitchen.

At the same time, I’m upset at myself for not having enough self-respect to stand up to my husband, frustrated that I need to be his mother, and the worst part is the toll on my children. But I feel guilty when I don’t do what’s asked of me. I am scared to pull back because he needs me. I feel that endlessly taking care of other people and expecting nothing in return is sometimes what it takes to be a good wife and mother.

Analysis
Rabbi Dr. Benzion Twerski has been counseling alcoholics and their codependent family members for the past 30 years. Formerly staff psychologist at Substance Abuse Services at Elizabeth General Medical Center (now Trinitas Hospital), he currently serves on the professional advisory board of JACS (Jewish Alcoholics, Chemically dependent persons, and Significant others). He’s been published in lay and professional periodicals, and lectures on addictions and shalom bayis in the Jewish community. He trains rabbanim, askanim, and chassan/kallah teachers on shalom bayis counseling at TCCI (Twerski Coaching and Counseling Institute).

A classic codependent, this wife expects her actions to fix her husband’s addiction. She quickly abandoned the life that was her own: her needs, responsibilities, and even her dignity. She fell into the trap of protecting him, catering to his intoxication.

But instead of stopping him, she’s enabling his destructive pattern.

Understandably, she’s become consumed with constant anger and guilt. That’s because the mission to “improve someone” always fails, and life on this track becomes unbearable.
The codependent is frustrated by his failure to control the addict, but addresses this by intensifying efforts to achieve the impossible. Marriages, other family connections, friendships, all become the object of manipulation in order to affect the addiction. But these efforts never work. What codependents need to understand is that it’s impossible to “fix” others. The result of attempting the impossible is unmanageability.

Like her husband, the codependent has her own unhealthy needs that cause her to enable him. She feels she has no choice, but she can choose not to control, and not to be a victim.
What does “victim” mean? Often, the emotional state of the codependent becomes dependent on the “blood alcohol level” of the alcoholic. A famous Al-Anon joke: The wife wakes up, looks over at her husband, and says, “Good morning, honey, how am I?”

It’s a self-destructive stance, but the individual stuck in this situation cannot perceive it.

So, how to treat this scenario? In Al-Anon, a 12-step-based support fellowship for family members of alcoholics, one must recognize the “Three C’s of codependency”: “I didn’t Cause it, I can’t Control it, and I won’t Cure it.” In recovery from codependency, one stops the useless efforts to Control or Cure. One may love the addict, but hate the behavior, and in doing so, “detach with love.” In a supportive fellowship of others who’ve experienced this firsthand, one can learn to develop a life that isn’t dependent on the addict for emotional well-being.

One also learns about setting and living within boundaries. The codependent learns to take care of her own life. Every parent, including those of difficult children, must find places in their life to actually live for themselves, not others. Everyone is entitled to enjoyment; no one is here to be a slave.

This former Mrs. Fix-it can still fulfill her duties as a wife, but she can’t ignore her own needs to care for her husband. When the wife decides to engage in recovery, she stops doing the things that make it easier for him to drink — like reheating his dinner when he stops at a bar after work.

Every bond/relationship has negative features. Everyone struggles from time to time in navigating a relationship. But in codependency, there’s intensity instead of balance, an element of bouncing back and forth inconsistently. They’re too close or too distant, or a yo-yo of both.

This plays out most dramatically with addiction. There is a process of getting too close to, yet distancing from the addict. The push-pull is draining and ineffective. I once asked a spouse to describe life in her house. She began virtually plucking the petals off a daisy: “I love him, I hate him, I love him, I hate him.”

Another Al-Anon quote: “The alcoholic plays the fiddle, and the wife dances to the tune.” In recovery, you stop dancing to his tune. Therapy is recommended, and getting support from Al-Anon and CoDA can help transform the way you function.

The Over-involved Therapist

Sharona, a newly minted social worker, was enthusiastic about her job at a local mental health clinic. Her first client, Haya, had anorexic tendencies and depression and was ready to bare her soul. Sharona knew she was going to change Haya’s life.

During their first sessions, Haya poured her heart out, discussing her parents’ divorce, the late-night suicidal thoughts, her loneliness. Sharona listened intently, trying to appropriately express equal amounts of compassion, empathy, and shock. This poor girl, Sharona often thought as Haya cried, her voice shaking with sobs. Sharona was soothing, encouraging, and kind as she validated Haya’s feelings and demonstrated a genuine interest in helping her heal.

Haya felt so lucky to have gotten the best therapist — no one had ever cared about her so much. As Sharona put all her energy into their sessions, Haya began showing improvement. The social worker rejoiced in these small victories, proud to have made a difference.

As time went on, they continued the counseling, with both Sharona and Haya enjoying the sessions very much — too much, in fact, for them to end. Sessions would extend longer so they could chat about other things. And then Sharona began confiding in Haya about her own thoughts and fears and dreams.

Analysis
Marcy Davidovics, LCSW, is in private practice in Queens and Manhattan and has been the social work director at Yeshiva of Central Queens for the past 14 years. She has one of the largest supervision programs, training frum MSW students in field work and practice. She has advanced training in many areas including marriage therapy, family systems, CBT, and divorce mediation.

Sharona has good intentions; she wants to give therapy her all. Haya feels validated and safe, and likely relieved to be listened to so well. We don’t know much about Haya’s history, but she states that “no one had ever cared about her so much.”

Now that Haya’s therapeutic needs are being met, as evidenced by reduced symptoms, the next step is discussing termination. Yet Sharona is having transference issues toward her client, wanting to rescue Haya, which connects her in an unhealthy way.

Sharona allows the therapy to become too informal by engaging in nontherapeutic talk and exceeding session time. This distorts boundaries. Self-disclosing Sharona’s own feelings, which has no therapeutic benefit to Haya, compromises the mutuality between therapist and client.

The therapist is the one responsible for setting boundaries. When a therapist shares personal information with the client, it can lead the client to become too emotionally dependent on the therapist, or render the client unable to self-determine the continuing course of treatment.

This type of codependent relationship can occur between parent and child, seminary madrichah and her chanichot, boss and employee. If a boss places unreasonable demands on an employee, and the worker says “yes” even though it impinges on her family or her functioning at home, the worker may have a huge need to please and in doing so, loses her sense of self. This may be Sharona’s issue as well.

I’ve seen this dynamic play out numerous times as a clinical supervisor. One supervisee, who was seeing a seven-year-old girl from a dysfunctional family, had a strong desire to “take the child home to raise her.” The child, feeling the maternal care from the clinician, would cling to the clinician in the hallways. The supervisee would hug her back, eager to validate how much she was helping the child. The child was in the therapist’s thoughts constantly.

In supervision, we discussed my supervisee’s strong need to be loved by her own mother. She saw herself in the little girl, and was eager to resolve her childhood lack by giving the girl what she didn’t have. I explained the necessity to create clearer boundaries by focusing on the child, not her own needs.

Like my supervisee, Sharona’s need to connect to Haya informally may be a sign of an unresolved codependent issue. Sharona may want to continue that relationship so she feels loved, supported, and/or validated. Likewise, Haya may need to listen to Sharona to feel resolved in her own issues, especially as her parents divorced and another separation is happening between her and Sharona. Preserving this relationship can be a cover for deeper feelings of pain or loss.

Perhaps either woman lacks real friends and is desperate for a sense of connection. A therapist with appropriate boundaries would lead therapy back to Haya’s desire to stay overtime and what that represents. The therapist would become self-aware of her own void and seek friendships outside her clientele.

Another possibility: Abandonment issues are playing out — Sharona is afraid of losing the client she worked so hard with, while Haya is concerned she will not be able to remain independent. A clinician should empower her client to become self-aware and individuated enough to eventually cope on her own.

Sharona should get supervision/therapy to talk about her feelings toward Haya. She also could establish further social interaction in her life, rendering her less vulnerable to using clients for friendship. On that note: Self-care for the therapist is imperative. Davening, hobbies, family time, and mental breaks are some ways to avoid the dependent/codependent dynamic with patients.
But most importantly, setting clear goals and boundaries with clients at the beginning of the relationship decreases the possibility of a breach in the process.

The Best Friends

When I was growing up, my mom was overworked and exhausted, always multitasking — washing dishes, calling the credit card company, putting away dinner. Although she was effusive when it came to hosting guests, or feeding us, I came to expect her sighs of frustration when she didn’t want to deal with me. I was a hard child — of that I am aware. My mother says I was very argumentative.

But to the outside world, I was the ultimate good girl: sympathetic, confident, sweet, an amazing student. Inside, I was a chameleon, an expert at shifting my personalities to become what anyone wanted me to be. My unconscious mission was to have everybody like me (or love me).

In nursing school, everyone knew I’d help them study, get notes, or just be there as a listening ear. I was especially close to Debbi, another frum woman. She opened up to me about her older sister’s untimely death, the depression she fell into a year before, and other family-related issues. I’d listen to Debbi for hours, comforting her; I enjoyed being there for her. As the year progressed, Debbi opened up more, confiding in me about her drug-taking habits and her high levels of paranoia and OCD.

When we weren’t together, I felt empty, like part of me wasn’t there. I missed her needing me. She began probing into my life, asking questions, and I started sharing things I’d never told anyone. No one had ever bestowed that kind of attention on me, and it felt nice.

Debbi was an even better listener than I was… emotionally validating, inhumanly patient, very selfless. So generous, in fact, that I had to stop telling her I hadn’t had breakfast that morning because she’d run to buy me a froyo or something and not let me pay her back. Since I never had time — or was too lazy — to prepare meals for our long hospital nursing shifts, I let her. She’d also bring presents — scarves, expensive perfumes. She didn’t have a lot of money, but would be crestfallen if I refused her.

We spent all our free time together. The friendship become all-encompassing — whenever I wasn’t talking to Debbi, I was thinking about her or texting her. Then there were the phone calls, ten a day — on both sides. She’d drop whatever she was doing to answer — even at crazy hours of the night. I turned to her for every minute decision — which direction to turn on the freeway if I was lost, what present to get my brother for his birthday.

Then came the day she asked me, “Will your husband love you as much as I do?” That’s when I realized this relationship was unhealthy. Because I was scared of the same thing: Who would I be without her?

Analysis
Chris Kingman, LCSW, has been helping people identify, understand, and change their codependent relational patterns for 15 years. He’s practiced individual and group therapy for the Jewish Board of Family and Children’s Services and has served as clinical supervisor, associate director and director of therapy centers in Manhattan and Brooklyn. Chris has a full-time private therapy practice in Manhattan.

Unknowingly, these two friends have drifted toward excessive dependency. The evidence for this is less about the exact amount of texting, thoughtful actions, and conversations — though these are not irrelevant. The problem is primarily revealed in two examples: The writer — let’s call her Eden — states: “When we weren’t together, I felt empty… whenever I wasn’t talking to Debbi, I was thinking about her or texting her.” Excessive preoccupation — tending toward obsession — with another person generally has the effect, over time, of destabilizing (rather than strengthening) one’s sense of self; it disrupts and threatens (rather than facilitating and supporting) one’s optimism about self and life, and one’s ability to function well in other relationships, at work, and overall in life.
We see this on the opposite side as well. When Debbi asks, “Will your husband love you as much as I do?” she reveals that her attachment to Eden has become possessive, confused, and probably increasingly fear-based. It’s on the basis of these feelings that Debbi would want to compare her love with that of Eden’s future husband.

So, how did this happen? As the saying goes, it takes two to tango.

During Eden’s childhood, she was taken care of materially, but not emotionally, which was undoubtedly very painful. To cope with the pain, Eden sought esteem from the outside world by adopting the persona of “the ultimate good girl” so “everybody would like me.” Eden experienced insufficient development of an authentic and integrated sense of herself (i.e., self-awareness, ability to recognize and set healthy boundaries), leaving her vulnerable to excessively gravitate toward what feels good in the moment — in this case, interactions with Debbi.

Debbi was obviously in the midst of her own ongoing emotional trauma, with the death of her older sister, other family issues, and self-medicating with drugs. Like Eden, Debbi’s untreated/unprocessed emotional pain played a large part in her readiness to escape reality into an ongoing preoccupation with Eden. In essence Debbi and Eden took turns: (1) regressing to a state of childlike dependency starving for nurturing, mirroring, and validation from the idealized all-giving parent figure; (2) assuming the role of the powerful parent who provided unlimited care.
How could Eden and Debbi have avoided drifting into a codependent relationship?

Human beings can avoid the development of codependent relationships via ever-increasing self-awareness and effective boundary-setting. Increased self-awareness would have allowed either woman to recognize how, together, they were unconsciously acting out the dynamics of their earliest relationships.

But insight is not enough. Also required is cultivation of the ability to establish norms, expectations, and patterns of communication that result in ever-increasing personal growth, clarity, and life expansion; these are the effects that healthy relationships have on us. Instead, the young women were headed in the direction of ever-increasing desperation and self-doubt, codependently clinging to each other with a subconscious hope/need to be saved.

The Chesed Girl

For her weekly school-mandated chesed, my 16-year-old daughter Liba was matched with an overwhelmed woman who just gave birth to triplets. Liba always stays longer than the required two hours, saying Masha needs her — if she’s not there, the house will be a wreck.

Masha sometimes calls my daughter on off days to ask her to take the kids to the park, babysit (pro bono), or help cook. Liba always says yes, even when she wants to say no. When I ask why she doesn’t just say she isn’t available, her answer is always, “Because she needs me.” In the beginning, Liba loved spending time there. “Ma, she’s so happy when I come,” Liba constantly told me. Lately, though, she’s been getting home more exhausted. She’s falling behind in her schoolwork and — she reported embarrassedly — fell asleep in class today.

Last Thursday, she left a friend’s birthday party to help Masha put the kids to sleep. I went over to see what was going on. The sight was surprising: Masha resting on the couch while my daughter was upstairs putting the older kids to bed. Seeing me, Masha looked startled, but beamed. “Your daughter is an angel. She won’t let me lift a finger, let alone get up from the couch. I wouldn’t survive without her.”

Analysis
Dr. Miriam Adahan is an expert in the field of Torah psychology and has written numerous books on healthy relationships. She offers classes in parenting and has a private practice in Jerusalem, Israel.
Darlene Lancer is a licensed marriage and family therapist and relationship and codependency expert. She has written Codependency for Dummies and Conquering Shame and Codependency: 8 Steps to Freeing the True You.

Chesed is beautiful. But there’s a difference between healthy “caregiving” and codependent “caretaking.”
Liba is not freely giving. She’d prefer to say no, but can’t. Liba ignores her own needs, feelings, and wants in deference to Masha. Helping has become a compulsion to the point of giving up nourishing activities, social life, academics, and sleep.

Self-esteem means valuing ourselves independent of others’ approval. Yet Liba’s self-esteem is based upon being needed and making Masha happy. In general, such compulsive caretaking is usually driven by unconscious shame, unhealthy guilt, a desire to impress the world with our accomplishments, or fear — of being rejected, punished, or ostracized. Some believe they must keep sacrificing in order to seem unselfish, but this is not true giving. It’s giving from a sense of lack rather than abundance.

Codependency takes two. Neither Liba nor Masha have boundaries. They’re both in danger of becoming codependent — Masha on Liba’s help and Liba on Masha’s praise. Masha seems to feel entitled (perhaps subconsciously) to Liba’s help by ignoring the two-hour limit — the boundary of their chesed relationship. In fact, Liba is beginning to take over Masha’s role as mother, which Masha appears happy to relinquish. It’s okay for Masha to ask for help, but not to expect Liba to do everything.

Yet we can’t blame Masha completely, because Liba is always available for her. It’s Liba’s responsibility to enforce these limits and Masha’s responsibility to accept them. Codependents rob the other person of making choices; they make themselves so available that they train the person to rely exclusively on them. And once this codependent relationship becomes set, it is very hard for Liba to pull away from Masha’s constant expectations of availability.

Although many times we put others’ needs before our own, it should be a conscious, not compulsive, decision that won’t jeopardize our welfare, and not one made to enhance our self-worth. We often have to give even if it’s inconvenient or uncomfortable. The problem arises when codependents seek to control others to meet their dependency needs. Codependents can hound, stalk, nag, pressure, and sulk quite well when their dependency needs aren’t satisfied. Codependents are not “nice” all the time — they may be seething inwardly. This may be why Rabbeinu Tam says that if you do a chesed out of coercion, without any pleasure in giving, it will ultimately harm the relationship.

In short-term or emergency situations, we give limitlessly. People can walk two miles to do the mitzvah of bikur cholim, and they’ll feel enlivened, joyous. But if there’s no joy in doing the chesed, and it’s done out of emotional blackmail, one should examine the relationship. It’s not kindness to allow ourselves to be exploited or manipulated.

Self-care is the hallmark of self-esteem. Liba’s mother should make sure her daughter understands the balance between giving and self-neglect. Hillel says, “If I am not for myself, who will be?” I have to sleep and eat properly, I can say no if I feel drained. Of course, this doesn’t give us permission to be selfish — the mishnah continues: “If I’m only for myself, what am I?”

The best way to say no without appearing harsh or uncaring is to use pareve “I” statements. For example, “I’m sorry, but I cannot handle that right now,” or, “It’s not convenient for me.”
If people reject her for not always being generous, she can protect herself by keeping her distance. A balance between chesed, giving, and gevurah, strength, means being able to say, “I’m exhausted, I need to rest.”

If the other person constantly says, “I need you anyway,” you’re not in a healthy relationship.

Love or Codependency?
Chris Kingman illuminates the difference:
It’s useful to think of love and codependency as very different ways or styles of attaching and relating to others in our personal relationships. Love, for the most part, empowers and facilitates feelings of safety and openness; love expands one’s life experiences and illuminates appealing possibilities.

Codependency, for the most part, disempowers and facilitates feelings of unsafety and guardedness, and constrains one’s life experiences and one’s sense of self. In a codependent relationship, you enable your partner’s unhealthy behaviors, and they enable yours. You minimize your needs and preferences. Instead of growing together, you deteriorate together. You feel devalued or disrespected by your partner. You feel frustrated or angry about how you’re being treated but you don’t speak up. You feel ashamed and embarrassed about what’s really going on in your relationship.

(Originally featured in Family First Issue 444.)

The post Disentangled first appeared on Mishpacha Magazine.

What happens if your new baby brings you anxiety and depression, instead of joy and delight? How to recognize —and recover from — postpartum reactions

"M

ommy I want to make you a birthday party ” Shloimy said eyes bright.

“Hmm,” Leba mumbled, her head ensconced in a novel.

“You know why, Mommy? Maybe if I make you a party, then you’ll smile.”

An English teacher by profession, Leba Katz was as normal as they come. She was geshikt too: Despite giving birth to her sixth child just months earlier, her family always had fresh suppers, clean laundry, and sparkling floors. Which is why, despite repeated red flags, it never dawned on her that something was wrong.

“My son’s remark should have been a bulletin from Shamayim,” Leba reflects. “But depression was for weirdos. I was Leba Katz, the oldest of a well-known heimishe family from Boro Park.”

It took another alarming incident for Leba and her husband to realize they needed help.

At 11:30 p.m. one night, Leba began walking out the door, wearing only a robe and socks. “Where are you going?” her husband asked incredulously.

“I’m leaving,” she declared. “I’m just going… somewhere.”

“This is crazy,” he said. “We’re going to a doctor.”

A Clinical Definition

Leba was suffering from postpartum depression (PPD), a form of maternal mental illness affecting at least one in eight — and as many as one in five — women across the world.

In the past, researchers referred to any post-birth mood disorder as “depression,” but today the medical world talks about postpartum reactions, acknowledging the range of conditions that can result from wildly fluctuating hormones: anxiety, bipolar disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), or a combination.

Not to be confused with baby blues, a short-lived bout of irritability affecting 90 percent of mothers for the first two weeks after birth, postpartum reactions generally do not go away without medical or therapeutic intervention — or an integration of both.

What’s more, a fast-growing body of research indicates that maternal mental illness does not always wait for delivery:

33 percent of women diagnosed with PPD developed the condition in their third trimester. Symptoms can also develop anytime in the baby’s first year of life — not just the first few months.

“With each child, the depression hit later and later,” Sari, a Baltimore mother of four relates. “With my youngest, I was fine until he was five months old. Then it hit.”

What causes maternal mental illness? A complex interplay of genes, stress, and hormones. “Hormones go up more than a hundredfold” during pregnancy, says Dr. Margaret Spinelli, director of the Maternal Mental Health Program in Columbia University, as quoted in the New York Times. After birth, hormones plummet, causing a crash that can “disrupt brain chemistry.”

Some primary risk factors are biological: Women whose moms had postpartum (PP) reactions are highly susceptible, and women who once experienced pregnancy-related depression have a 50 to 62 percent risk of recurrence.

Environmental factors also play a big role: the more stressors in a woman’s life — from financial strain to shalom bayis issues — the more likely she is to get a PP reaction. Experiencing a scare during pregnancy — even if it never materialized — can also trigger PPD.

Internal stressors impact a woman’s risk as well. A woman from a family of high achievers, for example, is at high risk. “She had a baby, she’s more limited, she can’t cope as well — but she’s expecting the same output of herself,” says Dr. Shula Wittenstein, a seasoned psychologist who works at Nitza, the Jerusalem Postpartum Support Network.

Perfectionists are more likely to fall into depression when their birth or after-birth experience does not go as planned, because they aim for “perfect” even in areas they can’t control. “Many women are brainwashed not to take an epidural, or told that a C-section will negatively affect the baby for life,” Dr. Wittenstein notes. “They’re also told nursing is a must. And they feel the powerful societal pressure to have many children in close succession, regardless of circumstance that warrant rabbinic instructions to the contrary.”

The result, asserts the psychologist, is that women aim for these goals even when they don’t have the capacity for them. And when they don’t succeed, they feel like failures.

Chaviva, who suffered from classic PPD, says, “I made myself insane trying to nurse, but it simply didn’t work. It took having three kids and consulting seven lactation consultants for me to accept that this is the way Hashem made me.”

Another internal stressor is the guilt felt when seeking a husband’s help. “The mother is drowning, but she doesn’t want to take away from her husband’s Torah,” describes Dr. Wittenstein. “She valiantly tries managing alone, pushing herself deeper into depression.”

Sari, an almost ten-year-veteran kollel wife, remembers feeling like a horrible Jew. “How could I ask him to stay home? I must have no chashivus haTorah, I’d think. Then I’d get angry at him for not offering to stay, thereby relieving me of the inner turmoil.”

A Glimpse into Darkness

Depression, the most common postpartum reaction, varies significantly in severity. Many affected women report a constant state of sadness and irritability.

Naturally upbeat and optimistic, Chaviva couldn’t find it in herself to smile. “Everything was wrong,” she remembers. “I couldn’t shake the anger.” Chaviva was unable to react to normal life challenges in a balanced way. When minor things went wrong, she would stew in a negative headspace — for days. “If my husband didn’t take out the garbage, he didn’t love me, my marriage was falling apart,” she says.

Other mothers paint a picture of perpetual “overwhelmedness.”

“Taking care of my kids just didn’t end. I felt I was being buried,” says Mindy. “My toddler whining, my baby crying — anything would set me off.” Mindy’s black feelings were exacerbated by a massive cloud of guilt: She had struggled with infertility for years. “G-d gave me these two amazing gifts after all these years — how could I not be happy?”

Rivka, who felt similarly submerged by routine responsibilities, says that in hindsight, she realizes her depression began in pregnancy. When she and her husband would read about their unborn baby’s weekly development, the soon-to-be-Tatty would get excited and emotional. Rivka, in contrast, would be completely detached.

“I kept telling myself: You can’t see the baby, that’s why you’re not feeling anything.” Months later, Rivka had no difficulty loving her sweet infant — she just couldn’t handle even life’s tiniest curveballs. “If I was in a rush and the baby had a dirty diaper, I’d lose it,” she recalls. “I couldn’t make decisions or problem-solve. I felt like I was about to crash — all day long.”

Most difficult to diagnose are cases of milder depression. Here, the woman functions outwardly — cooking and laundering, caring for the baby — but her inner world is in tatters.

“I put on a Broadway show. No one in the neighborhood could have known,” Leba says. “At home, though, I was in a fog. I wasn’t relating to my husband, my kids.”

For Shira, who held a high-powered finance job through several babies — and years of untreated depression — the farcical charade was the scariest part of it all. “I was having awful, awful thoughts: What’s the point? Why am I living? I knew I could do something really bad to myself, and no one would even know to prevent it.”

Years later, in a discussion about that bleak period, Shira’s husband remarked: “If you had stayed in bed for three days straight, I would have done something, gone for help. But you were totally functioning — I assumed you were just in a really bad mood.”

Beyond Depression

Other widespread postpartum reactions include anxiety, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).

“People don’t associate anxiety with birth, but it’s very, very common,” notes Dassy Gordon, coordinator at Nitza. She’s worked with mothers who were suddenly scared to leave the house, enter an elevator, or stay home alone. It’s a vicious cycle: If the anxiety deteriorates into a full-blown panic attack, the woman starts feeling anxiety about having another attack.

Anxiety often centers on the baby: Is she healthy? Happy? Developing right? In severe cases, a form of OCD may develop, where the mother constantly checks her baby’s breathing. Sometimes it manifests only in thought: The mother has to keep telling herself — again and again — “Everything will be okay.”

“Women suffering from OCD know it’s illogical,” Dassy says. “But they feel out of control. Their brains are being manipulated.”

Mindy, whose mother passed away suddenly when Mindy was in her eighth month of pregnancy, suffered from a mix of anxiety and PTSD. Coursing through every diaper change, bath, and bedtime was an underlying worry that she’d die too — leaving her children orphans.

“I was terrified. I was sure I would die, and who would take care of them?”

Birth is a particular trigger for PTSD: Studies suggest that the delivery process revives old stresses. What’s more, many women experience birth itself as a trauma, especially if there are complications.

“Birth can be very frightening,” Dassy observes. “It’s understandable that many mothers have to process this trauma.”

Using hormonal contraceptives after birth may exacerbate — or impersonate — maternal mental illness. While some gynecologists gloss over the side effects, many women experience radical mood swings and mistakenly assume they’re having a postpartum reaction. For others, hormonal treatment aggravates a preexisting condition, introducing new levels of despair.

“I had low-grade PPD for years,” shares Shira. “But it was only under the influence of hormonal treatment that I started having suicidal thoughts.” Shira found viable alternatives quickly.

PPD at Home

Maternal mental illness of any kind has a profound effect on the family. “Akeret habayit is not just a cute catchphrase,” says Dassy Gordon. “It’s reality.”

In extreme cases, the household stops functioning: Kids wear dirty clothing to school, hygiene falls by the wayside, the supper table remains empty.

In milder cases, the cogs keep turning, but the inner damage is acute. A mother with a postpartum reaction cannot attend to her children’s emotional needs. Her marriage is severely compromised. And her relationship with her baby can be frighteningly flawed.

“It was the worst at night,” Chaviva remembers. “She’d wake up, again, and I thought I would hurt her.”

Sari remembers thinking, I don’t want to look at this baby.

While most women experiencing such intrusive thoughts never hurt their children, writes Pam Belluck in an extensive New York Times piece on the subject, some take extreme measures to protect their babies. One woman  slid down the stairs in a sitting position for months because she’d imagined throwing her baby downstairs, reported Wendy N. Davis, the executive director of Postpartum Support International.

Maternal stress may cripple a woman’s ability to bond with or care for her child, studies indicate. As a result, the child’s emotional and cognitive health may suffer.

Dassy Gordon says passivity is a common fallout. Baby is developing a relationship with this world. When he smiles or cries and doesn’t get reactions, he subconsciously thinks, “Why should I smile or cry? What effect do I have on my surroundings?”

“These babies can become apathetic, lying in the crib for hours each day,” Dassy says. “They may grow into children who recoil from emotional attachment, who can’t build healthy relationships.”

Older siblings can also sustain long-term effects. Struggling with typical new-child jealousy and insecurity, they need extra love and attention. Instead, they might receive copious amounts of screaming and yelling, or feel obliged to take on a protective role, propping up a fragile mother who cries endlessly.

But, Dr. Wittenstein stresses, children are very resilient. If a woman seeks help in a timely manner, her kids will likely make a full recovery.

Beyond the children, the marriage relationship is obviously undermined. Many men — especially first-time fathers — are unfamiliar with postpartum reactions, and their ignorance adds insult to an already difficult dynamic. “You have a young boy who married a beautiful, charming wife,” Dassy Gordon says. “Then she’s sick for nine months straight. When she gives birth, he’s thinking, ‘Finally, I’ll have my happy wife back!’ But the opposite happens.”

Some husbands brush it off as “normal moodiness.” Then the wife starts making demands, and he gets resentful. “He doesn’t understand that he needs to stretch beyond his normal schedule to help her get past this,” Dr. Wittenstein says.

Sari blamed her husband for everything. Unwilling to admit another factor was at play, she attributed her never-ending upset to him: “If only you helped more, I wouldn’t feel this way.” The anger predictably intensified during high-pressure times like Yamim Noraim or Pesach. One Succos, she remembers not speaking to him all Yom Tov.

Shira, whose depression went undetected for years, felt deeply betrayed: She was in a dark pit, and her husband wasn’t pulling her out of it. “Every woman wants her husband to take care of her,” she says. “But I didn’t realize what was happening myself, and my husband didn’t pick up the cues.”

A Culture of Copers

Whether they suffer from depression, anxiety, or PTSD, frum women experiencing postpartum reactions face unique challenges. In a community that prides itself on large families and masterful juggling skills, mommies who are not managing feel enormous shame. And because of the emphasis placed on the beauty of motherhood (“Eim habanim semeichah!”), the woman who finds herself resenting — even hating — the role feels completely inadequate.

“We are raised with expectations about how happy we’ll be as mothers,” says Rebbetzin Michal Cohen, LCSW, a kallah teacher, social worker, and rebbetzin of Congregation Adas Yeshurun in Chicago. “Then you have a woman who can’t get out of bed, or has thoughts of hurting her baby. What is she supposed to think?”

“I lost my bren for Yiddishkeit,” Chaviva recalls. “Life was about keeping my head above water instead of becoming close to Hashem. I felt like a terrible Jew. I’d been so passionate in seminary, I had so many dreams… what happened?”

Chaviva’s pain was magnified by the fact that no one — not even her husband — validated her pain. When she reached out to mentors, they pooh-poohed her feelings, telling her it was normal to be overwhelmed after birth.

“That was the hardest part: not feeling heard,” Chaviva says.

When she finally went to the psychiatrist, who told her, “You have textbook PPD,” the relief was profound.

Denial of postpartum reactions is unfortunately not the exception. This flawed approach to mental health illness — resulting from community stigma or plain lack of awareness — can cause years of needless suffering, sometimes irrevocable emotional damage.

For Leba, it took six children and ten years of strained shalom bayis to seek help. Her refusal to face reality was part stigma, part ignorance. “My husband had a wife every other year,” she says sadly, adding that he was nothing short of a tzaddik for putting up with her. “I used to tell people: ‘It takes eight full months to recover from birth, you’re supposed to feel yucky!’ Looking back, I realize how abnormal that sounds.”

When Leba’s husband would show concern, wondering why she snapped so frequently at the kids, she’d say, “This is not medical, it’s avodas hamiddos.” When Leba finally made the trip to the doctor — at her husband’s insistence — she put up a tough fight.

“The doctor — who I’d already decided was a quack — recommended a mild antidepressant, and I was like, ‘Are you out of your mind? Do you know who you’re talking to? I’m Leba Katz, I’m normal!’ ”

“If your eyes weren’t working well, would you not get glasses?” the doctor matter-of-factly stated. “You’re missing some serotonin. That’s the whole story.”

The shame associated with therapy and mental health meds causes many frum women to delay treatment until the situation becomes untenable. “We have to be crawling on the floor, gasping our last breaths, in order to seek help,” rues Rebbetzin Cohen. “Why do we do that to ourselves? I wish therapy were one of the Aseres Hadibros: Thou shalt seek help.”

Another factor possibly aggravating PPD incidence in our community is the fact that there isn’t much emphasis on mothers taking care of themselves. Rebbetzin Cohen shares a telling incident: At the first session of a newly launched parenting class, she asked each woman to introduce herself. The questions included name, age, and range of children, and what each woman does to relax or unwind.

“Most of the women could not respond to the last question,” Rebbetzin Cohen reports. “I was floored. If you don’t outfit yourself with the oxygen mask first, your entire family will be comatose!”

Part of being a mother, says Rebbetzin Cohen, is making sure you are mentally and emotionally capable of caring for your kids. A 45-minute exercise routine is just as important — if not more so — than making a fresh supper.

“After all these years, I finally started treating myself to facials,” says Shira. “It sounds silly, but the emotional impact is real. Someone is taking care of you.”

Precisely when families are large, it’s critical that women stay on top of their emotional wellbeing. The larger the family, the more children are affected each time Mommy lapses into a postpartum reaction.

Getting Help

Treatment for postpartum reactions involves a multipronged approach of physical support, emotional support, therapy, and medication.

The first stop for a woman who suspects PPD is her obstetrician, who might refer her to a psychiatrist to evaluate if medication — usually in the form of antidepressants — is necessary. Next, the woman might call a postpartum support network like Nitza, who would refer her to a qualified therapist, hook her up with a support group, or arrange for a “phone friend” — based on her preferences.

Fearful of side effects to their unborn or nursing babies, many women are wary of taking medication (though research indicates the risk is minimal). But the damage of not taking it might be far more serious.

Mindy, whose psychiatrist prescribed a low-dose antidepressant, says the impact was immediate. “Within a week, I saw a difference,” she says. “I was reluctant to take it, but eventually I realized: You take Motrin for a headache, antibiotics for an infection, and antidepressants for mental illness.”

Leba’s results on medication were so positive that she’s continuing to take them, even though her baby is now pushing two. “I’ll get off of them one day. In the meantime, I have to be an effective mother.”

For Chaviva, landing on the right medication and dosage took time. “It’s not an instant happy pill,” she says. “But it did allow me to become grounded again. Life’s ups and downs kept coming, but the downs didn’t send me flying down a staircase anymore.”

Therapy is another critical treatment piece. It often comes in the form of cognitive-behavioral therapy (CBT), a structured, present-oriented psychotherapy focused on solving current problems and recasting negative patterns; or of psychodynamic therapy, a more analytical approach that examines the client’s past to reveal the unconscious intent of his actions or choices,

Therapeutic healing is also essential. This refers to a woman sharing her experience: letting go of the guilt, shedding feelings of inferiority, and internalizing that postpartum reactions could happen to anyone.

These feelings are facilitated when mothers speak openly with each other, normalizing the condition.

“Instead of pretending you have the perfect life,” Dr. Wittenstein urges, “share your story. For every person who courageously shares, so many others are affected.”

Alternative healing methods like reflexology or massage may be beneficial. But, warns Esther Gross, author of You Are Not Alone and moderator of a Williamsburg-based support group, these alone cannot be effective. “It’s like using an ACE bandage for a broken foot,” she says. “I meet women who spend $30,000 a year on alternative healing. I tell them: ‘Stop sabotaging yourself. Go to a doctor.’ ”

The importance of a solid support system in treating PPD cannot be overemphasized: Research indicates that proper social support (regular phone calls, home visits, offers of help, empathy) can reduce symptoms by 50 percent.

Husbands especially must be on board, offering extensive technical help and showing support for the interventions. Chaviva’s husband’s rosh yeshivah unilaterally directed her husband to make himself available both physically and emotionally.

“It’s funny — now that I know he’s available, I don’t need his help as much,” she says. “Knowing he’s there physically is so important to me emotionally.”

In contrast, Sari — who’s endured PPD four times — has developed some coping mechanisms, but she still hasn’t gone for professional help. “I wish my husband would put his foot down and tell me: I’m going to watch the baby and you have to go,” she says. “He’s just not that type.”

But whether or not Husband “gets it,” women like Sari must realize they deserve to take care of themselves. The short-term babysitting technicalities pale in comparison to the potential fallout of non-treatment.

A narrow slice of PPD cases resolve spontaneously within three years. Most untreated cases deteriorate or become chronic. And because depression often occurs with comorbidities like anxiety or PTSD, the depression may diminish while the comorbidity remains.

“A 45-year-old woman may still be suffering from postpartum depression,” says Dr. Wittenstein. “With each year, the impact becomes progressively more severe.” This means that at first, PPD struck an otherwise healthy family. Now, after years of abstaining from treatment, the mother must deal with PPD along with a host of marital and parenting issues that developed as a result.

What’s more, Dr. Wittenstein tells mothers, even if the condition fades away, “Two to three years is a long time to live like this. For you and your family.”

Preparation and Prevention

Women who endured postpartum reactions are generally determined to use every means at their disposal to avoid a repeat experience.

“Next baby, I will not leave the hospital before going on medication,” Mindy says. “I will pursue therapy before birth, while I’m pregnant.”

“I will get more help,” Chaviva says resolutely. “No one else can mother my kids, but lots of people can wash dishes, fold laundry, and cook supper.”

“I’m open to bottle-feeding,” Rivka says, recalling the physical pain that plunged her further into depression. “I wanted to nurse so badly, but I’d do anything — anything — to avoid this again.”

On a communal level, reducing the rate and severity of postpartum reactions requires greater awareness and open discussion. Dr. Wittenstein feels strongly that childbirth education classes should include more emphasis on “not-dream births” and associated feelings of inadequacy and shock. Expectant mothers must learn more about PPD and its red flags, in a clear, non-alarming way.

“I assumed every woman with PPD was suicidal,” says Rivka, who suffered from milder depression. “If I’d only known to get help, I could have avoided two years of misery.”

Husbands must be especially prepared, since they are often the only ones in a position to help. Dr. Wittenstein’s dream is for every rosh kollel or rebbi to check in with new fathers every few weeks after birth, asking, “Is your wife getting enough sleep? Is she back to herself? Is there anything you’re concerned about?” Rabbanim should be supportive, lightening the pressure of husbands who may need to spend more time at home. Neighborly nurturing after birth is far-reaching. Besides meals and babysitting, women should try to tune in to the emotional needs of kimpeturin mothers. “Instead of only asking, ‘How are you managing?’ try asking, ‘How are you feeling? Are you happy with the baby?’ ” suggests Dassy Gordon.

Most of all, mothers must validate, validate, validate, scratching out the stigma with every conversation — so that women like Sari feel comfortable seeking help. “Even after experiencing depression many times, it’s so hard to face it,” says Sari. “I’m still convincing myself: If I ignore it, it will go away.”

Meanwhile, women like Leba — who have found relief through medication and support — are continually stunned at how joyful and manageable motherhood can be.

“I am beyond crazy about my baby,” Leba says. “He’s 24 months; I’m still nursing him; I’m hopelessly attached. I feel like he’s my first kid.”

Depression  Dads

A little-known cousin of maternal mental illness, paternal postnatal depression (PPND) affects as many as 14 percent of fathers in the US. Experts dub it the “underscreened, underdiagnosed, and undertreated condition,” contending that real incidence is probably much higher, since men are less likely to report symptoms.

Depression in fathers presents differently than in their female counterparts: while men exhibit more traditional symptoms like fatigue, loss of appetite, or low motivation, they are less inclined to cry or show sadness.

Which men are vulnerable? Researchers have found a strong link between maternal depression and PPND, likely due to poor marital satisfaction. Some studies even propose that maternal depression causes PPND. But regardless of the mother’s condition, first-time fathers, unemployed fathers, and fathers of kids with special needs are associated with the highest rates of PPND.

And while the effects of PPND are milder than those of maternal depression, normal child development can still be hampered. Research indicates that children whose parents are not depressed have a 6 percent rate of emotional or behavioral problems. In homes where only the father was depressed, 11 percent of children will develop problems; where only the mother had symptoms, the rate among children was 19 percent.

Alarmingly, a child with two depressed parents has a 1 in 4 chance of having emotional or behavioral problems later in life. So both mothers and fathers should be on the lookout for the telltale signs of depression — and deal with them swiftly.

(Originally featured in Family First Issue 425)

The post Delivery from Darkness first appeared on Mishpacha Magazine.

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fter years of profound physical and verbal abuse Tamara was determined to move forward. “I’d been carrying a ton of baggage since childhood and I wanted to throw it overboard” she says. “I was willing to take a beating and do the hard work.”

A social worker friend recommended a therapist and Tamara dove in. Several sessions later she was frustrated — and out a considerable sum of money.

“It was a total flop” Tamara sums up wearily. “The therapist was too focused on my feelings — she kept repeating and summarizing my words. I’m very self-aware. I’m in touch with my emotions and didn’t want to get mired in the past. My goal was to acquire tools for more positive daily interactions.”

After several sessions Tamara tactfully expressed her dissatisfaction requesting a more results-oriented approach. When no changes were forthcoming she gave up.

“I’m burned out” Tamara says. “I so badly wanted this therapy to work. I was willing to give it my all. But now I’m drained — and I don’t have the money or energy to try again.”

The Therapeutic Shidduch

Sadly Tamara’s story is typical. For numerous therapy-seekers the search for an effective professional proves to be a harrowing journey rife with wrong turns acute disappointment — and in the worst cases permanent damage.

“Finding a good therapist is like finding a shidduch” says Dr. Yisrael Levitz director of the Family Institute of Neve Yerushalayim a post-graduate training center and clinic offering a broad range of mental health services toJerusalem’s religious community. “Say ‘I will!’ after minimal checking and you’re bound for trouble.”

But before considering the qualities to look for in a competent mental health professional consumers must understand what psychotherapy is — and isn’t.

“Psychotherapy is not advice-giving” Dr. Levitz clarifies. “It’s more a process by which individuals learn to better understand their thoughts and emotions and become freer to cope more rationally with the painful issues in their lives. Good psychotherapy should help an individual regain the bechirah that’s been lost due to overwhelming emotional pain.”

Untrained therapists often ply clients with intuitive advice. It may or may not be wise counsel Dr. Levitz says but it’s not therapy.

“As soon as you tell someone what to do, you actually restrict their bechirah. The goal of therapy is for the client to emerge independent, with the tools to make good decisions on his own.”
Frum people are especially prone to mistaking therapy for counsel, because they’re used to approaching rabbanim with halachic and hashkafic questions. Dr. Michael Tobin, a Jerusalem psychologist with over 40 years experience, and who has trained and supervised therapists since 1992, notes that confused clients must be gently educated.

“A therapist is not a rav, and therapy is not daas Torah,” he says, noting the opposite is true as well.

More Training = Better Therapist

The first and most crucial element in the search for the right therapist is determining that the therapist has a strong academic background and received competent supervised clinical training.

“Acquiring academic knowledge without supervised training is like learning how to swim on land,” says Dr. Levitz. “It’s only when you jump into the water and are taught the proper strokes that you become a competent swimmer.”

Hands-on experience is important in all professions, but in psychotherapy, it’s the deal-breaker.

At Neve’s Family Institute, for example, postgraduate therapists (who have completed several years of graduate education) spend at least two more years acquiring intensive supervised experience, as they provide low-cost therapy to the religious community.

It’s unfortunately too easy to stumble upon inadequately trained therapists. Certification “factories” offer a year or two of education, then label their graduates as qualified, potentially causing serious harm.

“We usually get the carcasses they leave behind.” Dr. Levitz sighs. “Especially with marriage counseling — probably the most challenging form of counseling — there’s no way a person can become skilled in two years. Let the buyer beware.”

Shaindy learned this the hard way. Tight on cash, she sent her son Mendy to a “certified therapist” who advertised very affordable rates. After two years of therapy and no progress, Shaindy dropped the arrangement.

“My son wasted two precious years,” Shaindy recounts. “When we finally found the right therapist, Mendy was practically an adolescent, much more resistant to therapy.”

Weeding out amateurish therapists is challenging because, unlike the “doctor” title, the term “therapist” is frequently self-conferred, accorded at will without objective criteria.

Once, a rav asked Dr. Levitz to ascertain the competence of a certain therapist. In a five-minute phone conversation, the seasoned psychologist learned some disappointing truths.
“What’s your experience?” Dr. Levitz asked.

“I’ve helped hundreds of people. I’m very good at what I do.”

“What’s your education?”

“I used to ask Rav Wolbe what to do.”

“What kind of approach do you use?”

“Shittat atzmi [My own method].”

In other words, the fellow had no approach at all; he made it up as he went along.

“Would you ever see a doctor who practiced the ‘me approach’?” wonders Dr. Levitz aloud. “Even alternative medicine is based on defined concepts.”

Statements from therapists that radiate arrogance (“I know what I’m doing,” “I’m an expert,” etc.) are red flags.

“Therapy can take a lifetime to master,” Dr. Levitz says. “A therapist should be confident but humble, open and authentic.”

No Jack-of-All-Trades

Just as important as extensive training, however, is experience with the specific issue at hand.

Devorah Levinson of RELIEF Resources, a nonprofit Jewish mental health referral service, notes that therapists who “do it all” may not be the most effective. “Oftentimes, it’s the really good therapists who focus their energies on a distinct condition or therapeutic modality, becoming bona fide experts.”

If a therapist purports to specialize in a particular area, he should be able to show a minimum of three years’ experience dealing with that issue exclusively.

“This was my mistake,” relates Elisheva, a divorced mother of four whose well-meaning but nonproficient therapist nearly triggered a nervous breakdown. “I didn’t have the headspace to verify her expertise in post-divorce counseling. When I finally switched to a therapist whose specialty was divorce, the difference was astounding.”

Determining a professional’s degree of specialty is tricky. A referral from a reputable agency or recommendation from several professionals is usually the best option.

Still, warns Devorah Levinson, if therapy’s truly needed, one should never delay it because “it’s hard to find the right one.”

“Referral agencies like RELIEF are the Hatzolah of mental health. We saw that people weren’t getting the proper help quickly enough, so we did what we could to streamline the difficult search process.”

With a database of more than 3,000 therapists, RELIEF has developed an exhaustive screening process that includes an extensive questionnaire and submission of r?sum?s and copies of licenses, diplomas, supervision certificates, and other relevant documents. A face-to-face interview evaluates the therapist’s communication skills and manner, and calls to mentors and colleagues provide honest opinions on the individual’s skill and integrity.

After RELIEF refers a caller to a therapist, representatives follow up whenever possible, asking questions like “How was the experience?” or “What did you like or dislike about the therapist?”

This caller feedback (sometimes given anonymously) is crucial. Even in today’s more “progressive” frum world, many won’t volunteer the fact that they pursued therapy, which makes it difficult for a lone individual to solicit referrals. Agencies like RELIEF are in a unique position to critically assess a therapist.

For therapy-seekers in locations with no centralized referral source, their next best bet is to request recommendations from a recognized mental health expert in the area.

Whatever you do, warns Sharon, a US-based mom of three, don’t rely solely on a friend’s experience. Desperate for immediate trauma counseling, Sharon trusted a longtime friend and plunged into therapy with a neighborhood therapist.

“She didn’t understand me,” Sharon reflects. “I had terrible insomnia, and when I poured out my heart about the sleeplessness, she responded, ‘That’s no good! You need a good night’s sleep!’
“I’d leave the sessions more stressed than when I’d entered.”

The Feel Factor

Sharon’s anxiety-ridden experience underscores another vital element of effective therapy: The client must feel safe and comfortable.

“In most cases, a good rapport is fundamental,” declares Devorah Levinson. “Without it, you’ll see little progress.”

For a client to become empowered and independent, Dr. Levitz concurs, he cannot feel judged at any time — even in areas of halachah. “If a religious client relates that he wants to become a mechallel Shabbos, a religious therapist, as a committed Jew, might likely feel profoundly pained. The therapist may even have the urge to subtly ‘mussar’ him out of it. But a therapist would simply not be effective if he gave mussar, subtly or otherwise. He needs instead to help the client explore the psychological determinants for his decisions. By keeping the relationship judgment-free, it becomes safe to explore deeper psychological factors.”

Tova, a child-abuse survivor who went through two therapists before finding the right one, experienced this firsthand.

“My [third] therapist never hugged me or even touched me. But her love allowed me to really ‘hear’ her often-painful suggestions, especially when she talked about me being jealous or malicious.... Despite knowing my negative side very, very well, she accepted me… even liked me!” That acceptance, Tova says, was key to her emotional turnaround.

Complementary personalities are also likely to facilitate therapy’s success. Elisheva describes her second therapist as very laid-back. “I’m a worrywart, prone to acute anxiety. Just being around her relaxed me.”

Devorah Levinson of RELIEF tries to match personalities by picking up nuances over the telephone. “A rav called in search of a therapist for the child of a shul family. The parents had been noncompliant in the past, refusing to take their son to a psychiatrist, and now they’d grudgingly agreed to start therapy. I knew they’d need a firm, take-charge therapist who could elicit full cooperation, yet was also sensitive enough to address their concerns.”

Ayala, a widowed mother of six, specifically looked for a “tougher” children’s therapist in the years that followed her husband’s death. “I knew I’d need that, because I was too soft on my kids. I just felt so bad for them,” she explains.

An expert therapist, however, can adjust his manner according to the client’s readiness. “He’ll be soft and hard, gentle and tough,” says Dr. Michael Tobin. “At each stage, the therapist must gauge how hard he can nudge his client into growth.”

Member of the Tribe?

Many therapy-seekers assume they need a religious — or at least Jewish — therapist who can understand their values. Is this assumption valid?

“If he’s ultra-qualified and frum, that’s ideal,” says Dr. Levitz. “But the priority has to be: Is he trained? Is he an expert?”

Devorah Levinson wholeheartedly agrees. “Some parents lament, ‘Why isn’t there a frum treatment program for people with anorexia?’ I reply, ‘The primary focus should not be that we want a frum program — rather, we want the best program.’ Once we find the most cutting-edge facility, most doctors and professionals are more than willing to accommodate religious sensitivities.”

What’s more, a true expert will have encountered enough religious Jews in his practice to become familiar with the frum lifestyle — and empathetic to our unique challenges.

Defined conditions like trauma, phobias, addictions, mania, depression, or personality disorders are often treated successfully by non-Jewish or irreligious therapists.

On the other hand, obsessive-compulsive disorder (OCD) frequently requires a good understanding of Jewish law because it emerges in activities important to the person — and Yiddishkeit is important to religious Jews. The OCD often manifests in mitzvos like hand-washing, Krias Shema, or Pesach cleaning.

Moishy, for instance, was able to find a qualified local therapist in his small town to help with his severe OCD, which expressed itself in kashrus. But he’d spend three-quarters of each session explaining concepts like milchigs and fleishigs — an expensive and tiresome transmission of Judaism basics.

Family and marital issues are also tricky in an irreligious setting. “A religious marriage involves practices that are often poorly understood or alien to the world at large and require an extensive knowledge of halachah. I’d be reluctant to recommend a secular therapist who is not sensitive and knowledgeable about halachic marital practices,” says Dr. Levitz.

Disdain can crop up regarding other aspects of frum lifestyle too. When her son’s therapist began making disparaging remarks about the chareidi school system, Shoshana was wise to back out. “I needed someone who’d help me work within the system. I didn’t want to feel defensive.”

For those who are self-conscious about therapy, “outsider” professionals might be preferable. “I didn’t want to bump into my therapist at the supermarket,” another woman says.

Whether you go heimish or not, Dr. Michael Tobin asserts, it’s a good idea to establish that the therapist has a stable personal life and hasn’t been through multiple marriages and divorces.
“The well-known saying goes, ‘A client gets no further than where his therapist is stuck.’ If your therapist is not worked-through, your progress will be limited.”

The therapist’s gender may affect comfort and efficacy too. Clients must be sufficiently self-aware to determine if an opposite-gender therapist will cause unease, or lead to inappropriate interactions.
Chaya, who pursued marital therapy, ultimately switched to a male therapist after noting her husband’s dissatisfaction. “My husband felt our original therapist, a woman, was partial to me, and that made him lose interest in cooperating,” Chaya recalls.

The Phone Call

Once you’ve amassed some recommendations, it’s wise to conduct a mini phone interview with each. “Be an educated consumer,” advises Devorah Levinson. “These therapists are selling a service. Ask questions, get information.”

Queries like “What’s your experience?” “What are your specialties?” and “This is my problem — how would you plan on helping me?” yield valuable clues as to the therapist’s competence and manner.

“The therapist should be able to explain — in layman’s terms — how he plans on helping the client,” says Dr. Levitz. “More important than the choice of approach is the existence of an approach. You want a man with a plan, not someone who is fumbling along.”

If the therapist sounds abrupt, harried, or dismissive, that might presage what your sessions will be like.

“I don’t have a secretary because I want to answer that initial phone call myself,” shares Dr. Tobin. “Most callers have been ruminating about therapy for a while — they’re anxious, they might feel a stigma. Now that they’ve taken the first step, I put them at ease about the therapy process, spend ten minutes getting a feel for their issues. Every potential client deserves that courtesy.”

Many callers want to know “How long will it take?” Because therapy is tailor-made, however, it’s hard to offer an accurate estimate until a proper meeting has taken place.

“Some people are in and out after three sessions,” says Dr. Tobin. “For complex problems, even three to six months would be illusory.”

Real therapy, the veteran psychologist ruefully notes, does not conform to the guidelines of insurance companies. “An honest, ethical therapist knows full well how challenging (though doable!) it is for people to change,” Dr. Tobin says. “They’ll be realistic about time-frame.”

Clients can expedite the process by arriving with a clear list of goals.

“Most people come with a vague sense of ‘my life is not working,’ or ‘the problem is my husband,’” Dr. Tobin relates. “While a skilled therapist will pinpoint the underlying issues rather quickly, it still takes time.”

Evaluating the Process… in Real Time

Even with the right therapist, you need to take inventory of your emotions after each session: Do I feel safe? Hopeful? Empowered?

“Overall, after most appointments, you should feel positive about your care,” says Devorah Levinson.

But “feeling positive” Dr. Tobin qualifies, doesn’t refer to a touchy-feely, life-is-hunky-dory sensation.

“Therapy is not relaxing,” he punctures the myth. “Change is hard, and feeling drained is normal.”

“It’s okay to be a little disturbed or stirred up by the therapist,” agrees Tova, a seasoned psychotherapy goer. “But this should always happen within the backdrop of the therapist caring for the client, and the client should feel that care.”

“Trust your instinct,” Tamara advises, looking back at her failed therapy experience. “I had a hunch it wasn’t going to be effective, but I so wanted it to work that I pushed on — foolishly.”

Red flags of ineptitude or substandard professionalism include a therapist’s answering the phone during a session (“I’d fire him on the spot,” Dr. Tobin says), looking distracted, forgetting something important he’s been told, or falling asleep. (Yes, it happens!)

“Expect 100 percent attention,” Dr. Tobin says. In this area, he’s a relentless, dogmatic supervisor. “Anything less is stealing. For every moment she’s in that chair, the client must feel she’s the most important person in the therapist’s life.”

“It bothered me that my original therapist didn’t remember key names or people I’d talked about, or what they had done,” relates Tova. “I had to repeat myself a lot.”

Tova also remembers a pattern of feigned understanding: The therapist would nod her head, but Tova — her client — could tell she wasn’t “getting it.”

“The therapist should be able to say, ‘I’m not sure what you mean, could you explain some more?’”

Beyond a pleasant, attentive relationship, at some point, clients must also see quantifiable results. “A nebulous ‘I think I feel better now’ means little,” Dr. Tobin says. “You want solid, describable accomplishments: ‘My relationship with my mother is healthier; I’m clearer about my life goals, etc.’”

For more measurable conditions like OCD or phobias, the key question is: Have symptoms decreased?

“The speed of change depends on the disorder and its severity, as well as the level of the clinician and motivation of the client,” Devorah Levinson says. “With moderate OCD, for example, if the client still washes hands every 45 minutes after two months of therapy, it might be a sign to reassess.”

Progress must also be continuous: If improvement has plateaued after several months, it may be time to move on.

“I was seeing a psychiatrist, and it was really helpful,” remembers Temi, who suffered from severe postpartum depression. “We identified childhood sources for some of my negative-thinking patterns, with the eventual goal of working to undo them.”

After a year, however, Temi felt her progress beginning to stagnate. “It was becoming a weekly kvetch session,” she says.

Temi switched to a more pragmatic licensed clinical social worker and made concrete behavior adjustments. But she doesn’t regret her psychiatrist visits. “Had I not gone through the first process, I could not have identified what I needed to work on. Each professional had his purpose.”

A bump in the therapy process does not usually warrant immediate termination; in fact, smooth sailing is the exception. The courteous — and worthwhile — thing to do is communicate openly with the therapist.

“There’s no room for discomfort here,” says Devorah Levinson. “By being up front, you’re giving your therapist the opportunity to better help you.”

A client who sees dubious progress might politely say: “We’ve been working for four months now, and I’m feeling a bit static. Can we discuss my goals?”

A good therapist won’t become defensive; he’ll appreciate his client’s motivation and alter his approach accordingly. And a really good therapist, Dr. Levitz adds, will preempt problems by soliciting feedback himself.

“He’ll ask ‘How did this go for you?’ or ‘How do you feel about our session?’ This communication is crucial, because the therapist’s and client’s perceptions often differ.”

It Ain’t Over Till It’s Over

Following candid discussion, if the client still feels unsatisfied, it’s probably time to part ways.

“But you have to be honest with yourself,” Devorah Levinson warns, citing a common pitfall. “Is your dissatisfaction coming from the discomfort of having to be in therapy altogether? Are you convincing yourself that therapy isn’t working because you hate the stigma or don’t like the ‘feel’ of being in therapy?”

Devorah notes that compliance — i.e., sticking it out — is challenging, especially in frum circles. “People go to therapy when they’re in crisis, but drop out when things start looking up, or when they begin medication. Six months later, the crisis hits again — with a vengeance.”

While the stigma associated with mental health services has diminished in recent years, it still causes many people to forgo badly needed therapy. Mothers, who are especially ill at ease, or just unaccustomed to giving to themselves, tend to shrug off the need. Plus, therapy’s steep, often unreimbursed expense gives deliberating individuals yet another reason to abstain.

Ultimately, though, it’s a question of priorities.

“People will pay hundreds of dollars on vitamins, but don’t have money for therapy,” laments Devorah Levinson.

If someone with strep failed to see a doctor, he’d be negligent. Similarly, contends Temi, a former PPD sufferer, taking care of one’s mental health is a serious obligation. “It’s our responsibility to use the tools Hashem’s given us to make things better. We have to do our part.”

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The myriad ABC permutations that trail a mental health professional’s name can be dizzying. Here’s a mini-primer on the significance of the symbols.

MSW: A social worker who’s earned a master’s degree, but hasn’t completed the required hours for licensing — and cannot practice privately.

• LCSW: an MSW who’s received her license (L) after extensive supervised clinical (C) training, and is qualified to give therapy or work in case management.
• LMFT: a licensed marriage and family therapist who’s earned a graduate degree in psychology and/or marriage and family therapy, plus supervised experience. She’s not qualified to deal with issues unrelated to marriage and family, like OCD, anxiety, or personality disorders.
• LMHC/LPC: a licensed mental health counselor who’s earned a graduate degree in counseling and/or psychology, plus supervised experience. Similar to LCSW, the MHC education is focused on therapy for a broad range of disorders, but it does not cover case management.
• LCAT: a licensed creative arts therapist who’s earned a master’s in art therapy, music therapy, dance/movement therapy, or drama therapy, plus supervised experience.
• PhD: a licensed psychologist who’s earned a doctorate, usually with a focus on research.
• PsyD: a licensed psychologist who’s earned a doctorate, usually with a focus on patient therapy.

Did you know? In all states except West Virginia, psychologists must earn a doctorate in order to get licensed and see patients privately.

Money Matters

Therapy is rarely covered in full by insurance — especially when provided by top professionals. Are there options for cash-strapped, in-crisis families?

• Insurance. Medicaid or decent private plans usually cover (at least partially) a qualified therapist for typical problems. Many senior and specialty clinicians, however, won’t take insurance: The reimbursement level can be less than half of what they usually charge, with the added requirement of incessant paperwork. “Using your insurance can be like going to a clearance shoe sale,” quips Devorah Levinson of RELIEF. “You might find something that will do, but it probably won’t be the right color or perfect fit.”
• Be savvy. Agencies like RELIEF help navigate insurance labyrinths to obtain funding, particularly if you have out-of-network benefits or can prove your need for a niche professional, like a male Yiddish-speaker who specializes in OCD. If that doesn’t work, RELIEF connects callers with insurance advocacy groups, who, for a fee, can help you obtain coverage from recalcitrant insurance companies.
• Delegate. The patient is probably in no state to battle stubborn insurance representatives. A concerned family member or caretaker should do the legwork instead.
• The clinic route. Newer, subsidized therapists at clinics like OHEL’s Tikvah Center in Brooklyn or Jerusalem’s Neve Family Institute offer a full range of therapy services for children, adults, couples, and families under the supervision of highly qualified supervisors. The Neve Family Institute has a generously subsidized fee schedule with a maximum per-session fee of NIS 100, and is known to never turn anyone away for lack of funds. The downside: You’re getting someone with less experience.
• Community giving. Many leading therapists accept a certain number of cases as “maaser” or “klal” clients. Ask the therapist to take you on pro bono. Additionally, agencies like RELIEF can refer you to organizations that run patient funds for specific issues, like teenagers in crisis. However, there’s no free ride. To get the most out of every dollar, these funds will usually subsidize half of eight sessions rather than four full sessions. Their goal? To ensure you’ll stay in therapy as long as possible, for optimal results.
• Be up front. Most therapists will be flexible about rates, particularly once you’ve already begun and shown them you’re in for the long haul. “One woman was so relentless, so serious about changing,” shares Dr. Michael Tobin, “that I was happy to give her a significant reduction.” Even in complimentary cases, Dr. Tobin concedes that he’ll still charge something — $5, $10 — just to assure motivation. “The more serious the financial commitment, the more serious the client’s commitment. That’s human nature.”

(Originally featured in Family First Issue 380)

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