Factors that Put Jewish Americans at Risk for Mental Health Problems:
Continued traumatic effects of Holocaust and other oppression. Many Holocaust survivors experience mental health disorders, including PTSD and survivor guilt. Even second and third generation descendants of Holocaust survivors also show a higher prevalence of PTSD and other psychiatric symptoms. Debates about biologically based epigenetic changes in survivors persist, but there is consensus that survivor behavior impacts family dynamics and molds family members’ stress responses.
Jewish asylum seekers from the former Soviet Union who endured religious repression under Communism and suffered persecution even after the Soviet Union disbanded, arrived en masse in the U.S. in the late 1970s and onward. Some Soviet-Jewish refugees are “double-survivors” whose families fled Nazi-controlled countries, only to encounter discrimination, harassment and even executions in the Soviet Union and Russia. In America, these refugees have faced acculturation challenges in addition to language and vocational obstacles, leading to feelings of hopelessness, distress and demoralization. Cultural confusion stemming from intermarriage and increasing diversity among Jewish populations. With intermarriage rates as high as 58% among American Jews (and even higher among non-Orthodox Jews), many self-identified Jews have surnames or appearances that suggest different ethnic or religious affiliations, prompting some other Jews to question their authenticity or employers to deny time off work for Jewish holidays or Shiva. Some spouses who convert to Judaism on marriage feel alienated from their non-Jewish families of origin or unaccepted by the Jewish community. Some children of intermarriages or adoptees are of mixed race and endure both anti-Semitism and racism as well as stress-inducing questions about their identities even from strangers.
Stigma of mental illness in some Jewish communities. Mental illness carries considerable stigma in some Jewish communities, especially Hasidim, a small but growing segment of the Jewish population in the United States. With a tradition of “shiddach” (matchmaking) to arrange marriages, Hasidic families are vetted by the community and by marriage brokers for history of mental illness before making introductions. Members of this community may shun psychiatric treatment, particularly medications, for fear of limiting opportunities for marriage. Those who do seek treatment may choose non-Jewish providers or Catholic hospitals to avoid waiting room encounters with others in the community or name recognition by off-site Hasidic billing services.
Hesitancy to seek psychiatric services or some types of treatment. For various reasons, some Jews who seek help for mental health issues may choose to avoid psychiatrists in general, psychiatrists of certain backgrounds, and some modalities of treatment. Some religious adherents perceive psychiatrists in general are hostile to religion, and therefore may only seek services from psychiatrist who are Orthodox or observant Jews.
The field of psychoanalysis was developed by a group of predominantly Jewish physicians who felt marginalized by anti-Semitism in Austrian society. Jews may be more accustomed to seeking psychoanalysis or psychotherapy and therefore bypass needed psychiatric evaluations to identify possible medical/organic contributors to psychiatric symptoms.
Jewish Americans may have lower rates of alcoholic use disorders than some other populations—with rates of substance abuse for Jews reporting to average around 20%. However, many Jews who do need treatment for substance use disorders may avoid 12-step meetings because of the Christian roots of the program, the common location of meetings in church buildings, and the recitation of the Christian Lord’s Prayer in some meetings. Jews in need of treatment—and health professionals referring them for treatment—may not be aware of Jewish Alcohol & Chemically Dependent Persons & Significant Others (JACS) or synagogue-based Alcohol Anonymous (AA) or Narcotics Anonymous (NA) meetings.
Discrimination against and limited opportunities for women in some Jewish communities. Women in some traditional branches of Judaism encounter gender-segregated activities or discrimination that conflict with their own beliefs about the role of women in society and in religion. Jewish women who support defined gender roles and view their primary function as mothers and homemakers may experience anxiety or shame if unable to conceive quickly.
Prevalence of eating disorders. The Jewish community—especially Orthodox women—may be at higher risk for eating disorders and may also face barriers to treatment. Stigma about mental illness as well as a link between thinness and marriage arrangements in some Jewish community may lead to under-reporting of the illness and delayed treatment. The central role food plays in Jewish culture and religious observations may also complicate diagnosis and treatment. To stem the rise of eating disorders among Jewish and Israeli women an Israeli law passed in 2012 mandates a minimum body mass index of 18.5 for women in the modeling industry to discourage unhealthy weight aspirations. Clinicians treating Jewish women with eating disorders should be aware that differentiating dietary laws or religious fasting from eating disorders requires knowledge of Jewish practices.
Discrimination against same-sex relationships in some Jewish communities. Jews from traditional backgrounds that prohibit same-sex relationships may feel guilt and shame about same-sex attractions or relationships and may feel unwelcome in their families or their families’ synagogue. This can lead to feelings of abandonment or alienation. Some may migrate to more liberal branches of Judaism or seek LGBTQ-specific synagogues to practice Judaism, but this may not solve their inter-family issues.
Stress from emphasis on high academic achievement. Jewish-Americans who are not academically inclined or who have learning disorders (such as ADHD or dyslexia) may feel shame or loss of social status in a community that stresses high academic achievement. Difficulties in reading or learning can impede participation in many traditional Jewish rituals and milestones—such as Hebrew school and Bar/Bat Mitzvah—leading parents and children to feel marginalized in their own communities.
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Suggested Assessment and Treatment Recommendations
- Please see Suggested Assessment and Treatment Recommendations for Marginalized Populations
- Take a comprehensive social, cultural and religious history with all patients, including questions such as:
- Do you identify with a religion/race/culture/ethnicity?
- Does your family identify with a specific religion/race/culture/ethnicity?
- How does your religion/culture offer solace in times of stress?
- How does your religion/culture create conflicts/stress for you?
- Did you or your relatives ever seek asylum for religious or political persecution?
- Which holidays do you and your family of origin (or your acquired family) observe?
- Have you, your family, or your friends experienced direct or indirect threats or assaults related to your religion or cultural affiliation? Do you fear that such assaults could occur?
- What safeguards are in place to prevent or mitigate such events, should they occur?
- When inquiring about suicidal ideation, always ask about the role that their religion (and other supports) play in such plans.
- Screen and assess using appropriate instruments and terminology, asking clarifying questions when appropriate, and avoiding assumptions.
- Consider the use of validated measures to assess trauma, PTSD, depression, anxiety.
- Become familiar with the patient’s background, attitudes and affiliations, noting that “being Jewish” is defined and experienced differently by different individuals. Some view Judaism as a religion; some identify with “Jewish culture.” Attitudes toward Israel vary.
- Avoid references to the “Jewish race,” since the Nazis identified “Jews” as a race.
- Be aware that official and unofficial Jewish subgroups exist, and that observances vary from subgroup to subgroup, and from individual to individual. Asking about synagogue attendance, community or charity affiliations, dietary observances, Sabbath-keeping rituals, or dress codes help reveal individual attitudes and lifestyle. Note the patient’s choice of dress, hat, hair and hemline may not be reliable signifiers of religious affiliation.
- Be aware that people who are otherwise observant or religious may also engage in sexual practices that put them and their families at risk of serious, undetected sexually transmitted infections (STIs).
- Incorporate the strengths of patients in treatment plan. The following can help empower patients to recognize and gain strength from their religious background.
- Listen to the patient and validate—rather than devalue—religious or cultural identification and cultural concepts of distress to improve doctor-patient alliance and outcomes.
- Encourage support from immediate and extended family, friends, and/or community when appropriate.
- Incorporate religious or spiritual values of patients into the treatment plan when appropriate. Consult a religious leader or pastoral counselor if needed to tailor specific approaches to assessment and interventions.
- If appropriate for a particular patient, consider discussing how their traditions can combine with or reinforce contemporary techniques that support mental health. For example, traditional Jewish prayer practices that may decrease stress by simulating meditation and adding structure and routine.
- Provide psychoeducation about the potentially protective role of religion in mental health
- Some Jewish-Americans may had bad experiences in the past with other therapists or health care professionals who looked down on religious beliefs, disagreed with the tenets of Judaism, or even considered adherence to religion to be a mental disorder itself. Alerting patients to your own openness to learn and hear about their religion and to contemporary psychiatry’s attitudinal shifts of acceptance to religion can encourage trust, discussion and alliance.
- Talk to religious patients, including Jews, about how religion can provide strength that can assist in adherence to treatment and protect against suicide.
- Offer medication, if clinically indicated.
- Prescribe medication as needed and discuss medication use during ritual fasts or Passover food restrictions and address pork products in gelatin (which is sometimes used in medications, especially capsules).
- Ask questions, avoid assumptions: When it comes to religion, culture, or race, it is best to ask questions rather than making assumptions before offering answers.
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APA Mental Health: A Guide for Faith Leaders (2015) https://www.psychiatry.org/psychiatrists/cultural-competency/faith-community-partnership