Jewish folk healing and the ba'al shem tradition

1. Introduction

Version followed: the historical ba'al shem tradition as described in the Encyclopaedia Judaica entry by Gershom Scholem and the Jewish Encyclopedia entry by Kohler and Ginzberg (1906), the Ba'al Shem Tov as reconstructed by Moshe Rosman (Founder of Hasidism, 1996; revised paperback edition 2013); contemporary practice in Israel as described by Yuval Harari (2010) and Yoram Bilu (2009); the clinical approach of Bilu and Witztum (1993, 1995) and the DSM-5-TR Cultural Formulation Interview (CFI) for the therapist's own work.

What it is. "Jewish folk healing" is not a single therapy or a codified medical system. It is a broad, historically documented field of religious and folk practice within Jewish communities. A ba'al shem (plural ba'alei shem, "master of the Name") was a person believed to work wonders and cures through knowledge of the Tetragrammaton and other holy Names. From the late 13th century the term also described writers of amulets. From the 16th century many ba'alei shem appeared, especially in Germany and Poland. Some were prominent rabbis and Talmudic scholars. By the 17th and 18th centuries, many were not scholars and drew followings through claimed healing powers. They combined Kabbalistic practice (prayers, amulets, incantations) with folk remedies called segullot, and were thought to be most effective for mental disorders and for exorcism, including of the dybbuk (a possessing spirit, as the tradition holds it). [source: Scholem, Encyclopaedia Judaica, via Encyclopedia.com] The Jewish Encyclopedia names Elijah of Chelm (around 1500) as the earliest known bearer of the title and says that about two centuries later the role had become a profession. [source: Kohler and Ginzberg, Jewish Encyclopedia] Britannica's summary notes that their blend of faith healing and Kabbalah brought them into conflict with physicians, rabbis and followers of the Haskalah (Jewish Enlightenment). [source: Britannica summary]

The Ba'al Shem Tov. Rabbi Israel ben Eliezer (the "Besht", c. 1700–1760), founder of modern Hasidism, is the best-known bearer of the title. He rose to prominence in Międzybóż (Medzhybizh, now Ukraine). Tax registers there list "Balszem" living tax-exempt in a house owned by the Jewish community council (kahal) from the 1740s until his death. [source: Dynner 2013, reviewing Rosman] Rosman notes that documentary evidence about his life is "scanty and equivocal". The hagiographic collection Shivhei ha-Besht (printed 1814) serves "more to mythologize him than to describe him". [source: Rosman 2013, Project MUSE page; Dynner 2013]

What remains today. Harari describes the continuation of practical Kabbalah in 21st-century Israel. Dozens of practitioners, many of them rabbis or self-described kabbalists, serve clients who seek healing, protection or success. Their common terms are segulot (charms), hashba'ot (adjurations) and shemot (names). Practitioners' authority rests on a felt divine connection, family lineage, revelation by a holy figure, or technical knowledge of manuscripts. Clients judge practitioners by reputation and "the rate of success", which spreads by word of mouth. Amulets and charms are also sold through books and websites, sometimes in New Age styles. [source: Harari 2010] Among Moroccan Jews in Israel, veneration of saints (tsaddikim), pilgrimage to tombs and visitational dreams of the saint are central to ethnic identity. Bilu documents new shrines founded by Moroccan-born men and women after revelations, including women "saint impresarios" who work as healers. [source: Bilu and Abramovitch 1985; Bilu 2009] Clients from Haredi (ultra-Orthodox), Hasidic, Sephardi and Mizrahi backgrounds may also seek blessings from a rebbe or a kabbalist, or protection against the evil eye (ayin hara). How widespread each practice is in a given community is [uncertain: not verified].

How change happens (as the tradition holds it, and for the therapist). Within the tradition, healing comes from God through holy Names, the merit and blessing of the righteous, and protective segulot. These are religious claims, described here as communities hold them, neither affirmed nor dismissed. The psychotherapist does not practise any of this. For the therapist, change comes from understanding the client's own explanatory model and religious idioms of distress. The therapist then works within them, alongside the client's rabbinic and community authorities where the client wishes. Bilu and Witztum's approach adds religiously congruent metaphors, narratives and actions to standard secular treatment, and requires "a temporary suspension of disbelief" from both therapist and patient. [source: Bilu and Witztum 1993, abstract]

Who holds authority. Authority sits with the client's own rabbinic authorities: the communal rabbi (rav), halachic decisors (poskim) and, in Hasidic communities, the rebbe. Within practical Kabbalah it also sits with recognised kabbalists (mekubalim), and among Moroccan Jews with the saints and their shrine custodians. [source: Harari 2010; Bilu 2009; Doron et al. 2024] Rabbinic bodies have also spoken on mental health and safeguarding. The Rabbinical Council of America passed a resolution urging rabbis to destigmatise and refer. [source: Schwartz 2016] The Rabbinical Council of Victoria issued a 2010 advisory resolution that the prohibition on mesirah (informing to secular authorities) does not apply to child sexual abuse. [source: Royal Commission Case Study 22] There is no single licensing body for folk healers or kabbalists. [synthesis]

2. Framework

This is the therapist's own culturally responsive work alongside the tradition, not a phased protocol from the tradition. No source gives session counts for this work. The phases below are [synthesis], built on the CFI, Kleinman's explanatory model and the three areas of Bilu and Witztum's guidelines (context, therapist requirements, interventions). [source: Bilu and Witztum 1993; APA CFI]

Phase 0: Preparation (before and between sessions).

Goal: examine your own stance toward Orthodox Judaism and religious healing. Learn the basic vocabulary and adapt the setting.
Format: supervision, reading, consultation with a cultural broker. Bilu and Witztum treat the clinic's look and physical setting as part of treatment. [source: Bilu and Witztum 1993]
Move on when: you can name your likely countertransference reactions. Greenberg and Witztum's book warns against exoticism, premature distancing, seeing the patient as inferior, and pretending to be free of prejudice. [source: Psychiatric Services review of Sanity and Sanctity]

Phase 1: Engagement and trust (sessions 1–2, [synthesis]).

Goal: address stigma, confidentiality, the client's fears about the community, and any need for rabbinic sanction for therapy.
Move on when: the client agrees to continue and has said what kind of therapist they will accept.

Phase 2: Cultural assessment (sessions 1–3, [synthesis]).

Goal: complete the core CFI and the relevant supplementary modules (Spirituality, Religion and Moral Traditions; Explanatory Model; Coping and Help-Seeking; Social Network; Immigrants and Refugees where relevant). Map past and current help-seeking, including blessings, segulot, amulets, kabbalists and pilgrimages.
The core CFI's time is [uncertain]. The field trial found that later interviews needed less time but gave no minutes. [source: Lewis-Fernández et al. 2017]
Move on when: you can state the client's explanatory model in their own words and they agree with your summary.

Phase 3: Formulation and differential.

Goal: separate normative religious belief and experience (visitational dreams, attributions to ayin hara, sin or a curse, belief in a dybbuk) from a disorder that needs treatment. Use DSM-5-TR criteria and ICD-11 6B62/6B63, and consult a cultural broker or the client's rabbi with consent.
Move on when: you have a shared formulation with the client that holds both the religious meaning and the clinical picture.

Phase 4: Collaborative treatment.

Goal: deliver standard evidence-based treatment in religiously congruent language. Collaborate with the client's rabbi or refer to Orthodox clinicians if the client wishes, and route medication questions to the prescriber.
Format: individual sessions, plus family or rabbinic meetings with consent.
Review: at regular points, re-administer CFI modules as the APA allows (modules can be repeated during treatment). [source: CFI Supplementary Modules]

Phase 5: Integration and ending.

Goal: help the client integrate religious and folk-healing experiences into their account of recovery, and plan for relapse within community supports.

Throughout: safeguarding.

Abuse, exploitation, delay of urgent medical care or harm to others override confidentiality limits as the law and your code require. [synthesis; source: Royal Commission Case Study 22]

3. Guiding principles

The therapist works alongside the tradition, never in it. Do not write amulets, prescribe segulot, give blessings, interpret texts as halacha, or mediate exorcism. Refer religious acts to the client's authorities. [synthesis]
Describe, do not adjudicate. Holy Names, the evil eye, a dybbuk and a saint's dream visit are held as true within the tradition. Neither affirm nor dismiss them. Explore what they mean to the client. [synthesis]
Temporary suspension of disbelief. Enter the client's religious idiom far enough to work inside it. [source: Bilu and Witztum 1993]
The rabbi's authority may outrank therapy. Doron et al. note that halacha and the rabbi sit "elevated above therapy" for many Haredi clients. In practice, plan for rabbinic input instead of competing with it. [source: Doron et al. 2024]
Respect the client's own choice of authority. Different rabbis and communities differ. Ask whom the client follows rather than assuming. [synthesis]
Treat stigma and marriage prospects as real risks. The RCA-linked commentary names the "automatic disqualification" of potential spouses over family psychiatric history. In practice, discuss record-keeping and disclosure explicitly. [source: Schwartz 2016]
Cultural humility over expertise. Do not over-focus on culture at the cost of authenticity ("phoniness"). Avoid cultural imperialism and do not direct life decisions. [source: Doron et al. 2024]
Collective, not only individual. Family and community interests often come first, so formulate the problem at both levels. [source: Doron et al. 2024]
Name differences openly. Culturally responsive statements were associated with better outcomes, so speak about the secular–religious gap rather than avoid it. [source: Doron et al. 2024]
Watch your countertransference. Avoid exoticism, voyeurism, distancing and condescension. Take these to supervision. [source: Psychiatric Services review of Sanity and Sanctity]
Neither pathologise nor miss illness. Religious content does not make experience psychotic. Culturally normative experience does not rule out a disorder. [source: DSM-5 / ICD-11 criteria; synthesis]
No herbal or remedy advice, no medicine advice. Do not comment on folk remedies or on starting, stopping or changing medicines. Route to the prescriber. [synthesis]
Consent governs all collaboration. Contact a rabbi, kabbalist, family or community body only with the client's explicit consent, for a stated purpose. [synthesis]
Safeguarding is not suspended by religious law. Abuse reporting obligations stand. Rabbinic bodies have themselves ruled that the mesirah prohibition does not apply to child sexual abuse. [source: Royal Commission Case Study 22]
Touch. This work involves no touch. Any physical contact follows explicit consent and is never sexual. Some observant clients avoid cross-gender touch, including handshakes. Follow the client's lead. [synthesis]

4. Intervention inventory

All interventions below are the psychotherapist's own work. None involves performing, prescribing or imitating a ba'al shem's, kabbalist's or rabbi's healing. Example language is illustrative unless quoted and cited.

4.1 Cultural self-examination and countertransference review

Purpose / when: before the first session with an Orthodox, Hasidic, Sephardi or Mizrahi client, and whenever you notice strong reactions. The countertransference risks named in Sanity and Sanctity are exoticism and voyeurism, premature distancing, seeing the patient as inferior, and pretending to be free of prejudice. [source: Psychiatric Services review of Sanity and Sanctity] Doron et al. report that secular therapists may feel anger or distress, or feel their values are disrespected. They also report growth in humility and patience. [source: Doron et al. 2024]
Steps:
1. List your assumptions about religious authority, gender roles, family size, modesty and magic or amulets.
2. Note which of these you find admirable, exotic or objectionable.
3. Identify your own religious position (secular, other faith, Jewish but of another denomination, Orthodox) and how the client may read it. Greenberg and Witztum note their own mix of one secular and one Modern Orthodox author. [source: Psychiatric Services review]
4. Take the list to supervision or to a culturally knowledgeable consultant.
5. Repeat after any session where you felt amused, irritated, fascinated or superior. [synthesis]
Example language (to yourself or a supervisor, illustrative): "I noticed I wanted to argue when she said the illness came from an evil eye. What was that about for me?"
Watch for: curiosity that serves your interest more than the client's; avoiding religious topics; quietly treating religious explanations as symptoms. It is working when you can hear a religious account without the urge to correct or romanticise it.

4.2 Engagement: stigma, confidentiality and permission for therapy

Purpose / when: first contact and the first sessions. Seeking therapy can feel like "a failure on both a practical and a spiritual level", and clients may first try stricter observance. Secular therapists may be seen as outsiders who cannot be trusted. Some Haredi leaders have reportedly forbidden consultation with "heretic or atheist" clinicians. [source: Doron et al. 2024] Family psychiatric history can affect marriage prospects. [source: Schwartz 2016]
Steps:
1. Ask early whether the client has consulted, or needs to consult, a rav or rebbe about coming to therapy. Ask whether that person knows they are here.
2. Explain confidentiality and its legal limits in plain terms, including what is written in records and who can see them.
3. Ask directly what the client fears might happen if the community learned of therapy (e.g. marriage matches, children's school places, standing in the community). [synthesis; source: Schwartz 2016 on shidduch]
4. Agree on practical matters: appointment times that avoid Shabbat and festivals, how you will contact them, and whether a same-gender therapist is preferred. [synthesis]
5. Ask what would make the clinic feel acceptable. Bilu and Witztum treat the setting itself as part of treatment. [source: Bilu and Witztum 1993]
Example language (illustrative): "Some people I see have asked their rabbi before coming, and some prefer to keep it private. Either is fine. What would help you feel this is a safe place?" / "Let's be clear about what goes in your notes and who can read them."
Watch for: the client not returning after session one; requests for no written records (discuss honestly what is legally required); a family member insisting on attending. It is working when the client brings real material and comes back.

4.3 Core Cultural Formulation Interview (DSM-5-TR)

Purpose / when: initial assessment with any client. It suits a client whose distress is framed in religious terms (sin, punishment, the evil eye, a curse, spirits). The CFI clarifies the problem from the perspective of the individual and their social network. It covers what the problem means, possible sources of help, and what they expect from services. It has 16 questions in four domains: (1) cultural definition of the problem; (2) cultural perceptions of cause, context and support; (3) cultural factors affecting self-coping and past help-seeking; (4) cultural factors affecting current help-seeking, including the clinician–patient relationship. It supports clinical understanding and decision-making and is not meant to be the sole basis for a diagnosis. [source: APA DSM-5-TR CFI] APA permits clinicians to reproduce it for use with their own patients. Modification or translation needs APA permission. [source: APA DSM-5-TR CFI] Time needed is [uncertain]. The field trial found that subsequent interviews took less time, but its abstract gives no minutes. [source: Lewis-Fernández et al. 2017]
Steps:
1. Introduce it as a way to understand the problem "in your own words and your community's".
2. Work through the four domains in order using the official form; do not reword items in a way that changes them.
3. In domain 2, invite religious and folk explanations explicitly.
4. In domain 3, ask about all help already sought, including rabbis, rebbes, kabbalists, blessings, segulot, amulets, prayer and pilgrimages to tombs of the righteous.
5. In domain 4, ask how your being secular, female or male, Jewish or not, may affect the work.
6. Summarise back and note which supplementary modules to add.
Example language (illustrative, not CFI items): "People in your community sometimes understand this kind of trouble in religious terms. How do you and your family understand it?" / "Has anyone else been helping with this, such as a rav, a rebbe or someone who gives blessings or segulot?"
Watch for: guarded or formulaic answers (trust may not yet be there; come back to it); answers that change when a family member is present. It is working when the client corrects your summary in their own terms.

4.4 CFI supplementary modules and Informant Version

Purpose / when: when the core CFI shows a domain needs depth. The 12 modules include Explanatory Model; Social Network; Psychosocial Stressors; Spirituality, Religion and Moral Traditions; Cultural Identity; Coping and Help-Seeking; Patient–Clinician Relationship; School-Age Children and Adolescents; Older Adults; Immigrants and Refugees; and Caregivers. They can be add-ons or standalone, at the first evaluation, later, or repeated during treatment. The 17-question Informant Version is for a family member or friend. [source: APA CFI Supplementary Modules; APA CFI Informant Version]
Steps:
1. Use Spirituality, Religion and Moral Traditions for observance, community affiliation (e.g. Hasidic court, Lithuanian yeshiva world, Sephardi or Mizrahi community, Modern Orthodox) and moral conflict.
2. Use Coping and Help-Seeking to map religious and folk help in detail.
3. Use Social Network to map family, rabbinic and community supports and pressures.
4. Use Immigrants and Refugees for recent immigrants (e.g. Moroccan-born pilgrims and their families, whose saint veneration Bilu ties to ethnic identity). [source: Bilu and Abramovitch 1985]
5. Use School-Age Children and Adolescents with minors and Caregivers with parents.
6. Use the Informant Version with a spouse or parent, with the client's consent.
Example language (illustrative): "I'd like to understand more about the community you belong to and what it expects of you. Is that alright?"
Watch for: a parent or spouse answering for an adult client; module fatigue (spread modules across sessions). It is working when you can predict how the family and community will respond to treatment choices.

4.5 Exploring the explanatory model (Kleinman)

Purpose / when: whenever the client offers an explanation of their illness. Examples: an evil eye, a curse, a dybbuk, punishment for sin, a lapse in observance, or a blessing withheld. Kleinman, Eisenberg and Good (1978) give eight questions. Paraphrased, they ask what the client calls the problem, what caused it, why it started when it did, what it does and how it works, how severe it is and how long it will last, what treatment the client should receive, what problems it has caused, and what the client fears most. [source: Tanenbaum handout; Kleinman et al. 1978 as cited]
Steps:
1. Use the client's own term (e.g. ayin hara) rather than translating it into a symptom.
2. Ask the cause, timing and mechanism questions with curiosity.
3. Ask what the client expects to help, and who should provide it (rav, kabbalist, doctor, therapist).
4. Ask what they fear most. This often reveals stigma, marriage concerns or fear of eternal consequences [synthesis].
5. Note where their model and yours overlap (e.g. stress, family conflict, grief) and where they differ.
6. Negotiate a shared working model that leaves room for both. [synthesis]
Example language (illustrative): "You said this began after someone looked at your baby with envy. What do you think is happening, and what do you think would help?" / "What worries you most about it?"
Watch for: the client testing whether you will mock the explanation; your own urge to replace their model. It is working when the client adds detail and begins to link the religious account to their life events.

4.6 Non-judgemental inquiry into religious and folk help-seeking

Purpose / when: at assessment and at review points. Clients may consult rabbis or self-described kabbalists for healing, protection or success, sometimes paying for amulets or segulot, including online. Some clients seek harm to others through such practitioners. [source: Harari 2010] Moroccan Jewish clients may visit saints' tombs and shrines, or consult women healers associated with new shrines. [source: Bilu 2009]
Steps:
1. Ask whom they have consulted, what was advised, what they did, what it cost, and what effect they felt.
2. Ask whether any advice conflicts with medical or psychological treatment (e.g. advice to stop a medicine or to avoid a doctor). Do not comment on the advice yourself; route medical questions to the prescriber. [synthesis]
3. Ask whether any practitioner has asked for large sums, isolation from family, secrecy or physical contact. [synthesis]
4. Record the information neutrally in the client's terms.
5. Do not ask for, record or discuss the content of amulets, Names, adjurations or other religious texts. [synthesis]
Example language (illustrative): "Many people go to a rav or a mekubal when something like this happens. Have you? How was that for you?" / "Has anyone you consulted said anything about your doctor or your medication?"
Watch for: shame or secrecy about consulting a kabbalist (some rabbinic voices disapprove; the historical tradition records criticism from rabbis, physicians and the Haskalah) [source: Scholem, Encyclopaedia Judaica; Britannica summary]; escalating payments; a practitioner discouraging medical care. It is working when the client tells you about consultations without needing to hide them.

4.7 Distinguishing normative religious experience from disorder

Purpose / when: when religious content appears in symptoms. Examples: dreams of a saint or a dead tsaddik; belief in a dybbuk, possession or an evil eye; voices or visions of dark spirits; intense guilt over sins. The Sanity and Sanctity review describes yeshiva students reporting nightly visitations by dark spirits, and newly religious baalei teshuvah burdened by sins from before they became observant. [source: Psychiatric Services review] Bilu and Abramovitch describe visitational dreams of the saint as a culturally shared way of expressing personal problems, with therapeutic effects. [source: Bilu and Abramovitch 1985]
Criteria to use: DSM-5 DID Criterion A notes identity disruption "may be described in some cultures as an experience of possession". Criterion D excludes disturbance that is "a normal part of a broadly accepted cultural or religious practice". Dissociative trance falls under other specified dissociative disorder and is excluded when part of broadly accepted collective practice. DSM-5-TR retains these in substance; the exact wording is [uncertain]. [source: PMC9199574; Lewis 2023 study guide] ICD-11 6B62 trance disorder and 6B63 possession trance disorder require the state to be involuntary and unwanted and not part of accepted cultural or religious practice. [source: findacode ICD-11 mirror; PMC9199574] The DSM-5-TR note that culturally sanctioned beliefs should not count as psychotic symptoms is [uncertain: not verified]. No DSM-5-TR cultural concept of distress is specific to Jewish communities. [synthesis; source: UNMC DSM-5-TR slides list]
Steps:
1. Ask whether others in the client's community would see the experience as expected, as a sign of blessing or warning, or as unusual. With consent, ask a cultural broker or the client's rabbi the same. [synthesis]
2. Assess voluntariness, distress, impairment, duration and course.
3. Look for features beyond the religious idiom: disorganisation, functional decline, other first-rank symptoms, mood episodes, substance use, medical causes.
4. Consider obsessive-compulsive presentations where religious doubts and rituals are excessive and ego-dystonic. This is [synthesis]; a rabbi's view on what observance requires can help separate scrupulosity from normal piety.
5. Formulate both the religious meaning and the clinical picture, then share your view with the client respectfully.
Example language (illustrative): "In your community, would people expect a dream like this? Would they see it as a good sign?" / "It sounds very important to you. I also want to make sure the sleeplessness and fear are not something we can help medically."
Watch for: pathologising a shared belief; missing psychosis because content is religious; family pressure to see illness as possession, or the reverse. It is working when the formulation makes sense to both the client and a community-informed consultant.

4.8 Working within religious idioms of distress

Purpose / when: when the client's distress is carried in religious language and standard secular framing is not landing. Bilu and Witztum add religiously congruent metaphors, narratives and actions to standard secular treatment. Their case vignettes illustrate three types of religiously informed intervention: healing rituals, dream interpretation, and culturally congruent metaphors and stories. They also illustrate using a patient's religious symbols in PTSD treatment. [source: Bilu and Witztum 1993, 1995, published abstracts] One full case report by the same group shows the approach in practice: clinicians took up an ultra-Orthodox patient's own images (a desolate place re-framed as a desert, a journey towards an oasis, a revered saint, his late father) and built them into imagery work, with the wife keeping a diary of night-time episodes that opened each session. That treatment also used hypnosis delivered by trained clinicians; hypnotic procedures are not reproduced in this guide. [source: Bilu, Witztum and van der Hart 1990, author-hosted full text] The steps below draw on these sources for the use of the client's own images; their sequence is the writer's synthesis, not a published protocol [synthesis]. This guide limits the therapist to metaphor, narrative and meaning-making; any ritual act belongs to the client's own religious authorities, not to the therapist.
Steps:
1. Collect the client's own images, stories and texts that carry meaning for them (e.g. biblical figures, Hasidic tales, the life of a saint) without importing your own.
2. Use these images to name feelings and goals inside an evidence-based treatment (e.g. framing exposure or behavioural activation in the client's terms of strength, trust or return). [synthesis]
3. Where a dream of a saint or a tsaddik is brought, explore what the client felt and what the dream asks of them. Do not interpret it as a religious authority would. [synthesis; source: Bilu and Abramovitch 1985 for the cultural role of such dreams]
4. If the client wants a religious act (a blessing, a prayer, an amulet, a ritual of repentance), help them bring the question to their rav or community, and discuss what it means for them. [synthesis]
5. Check that the use of religious language strengthens the client's agency and does not replace treatment.
Example language (illustrative): "You said you feel like the story of being lost in the desert. What would the next step on that journey look like this week?" / "That sounds like a question for your rav. Would you like to bring it to him, and then tell me what you both decided?"
Watch for: the therapist drifting into religious instruction; phoniness or overuse of religious vocabulary [source: Doron et al. 2024]; the client feeling patronised. It is working when the client uses the shared images on their own between sessions.

4.9 Consultation and collaboration with the client's rabbi or rebbe

Purpose / when: when the client wishes, when halachic questions affect treatment, or when rabbinic sanction is needed for therapy, medication or a family intervention. Rabbis may be expected to take part in treatment, and halacha and the rabbi may be placed above therapy. [source: Doron et al. 2024] The RCA resolution calls on rabbis to learn to identify, refer and support congregants. NEFESH has rabbinic advisors and links professionals with rabbis and educators. [source: Schwartz 2016; NEFESH site] Trials in Nigeria, Ghana and a Ghanaian prayer camp show collaboration between traditional or faith healers and health workers can reduce psychotic symptoms. In the prayer-camp trial, chaining days did not fall significantly. These trials were not in Jewish communities, so their transfer is [synthesis]. [source: COSIMPO, Gureje et al. 2020; Ofori-Atta et al. trial]
Steps:
1. Ask whether the client wants their rav involved, for what purpose, and what may and may not be shared. Get written consent.
2. Prepare a short, jargon-free question (e.g. whether a treatment plan conflicts with observance, or how a fast affects a patient on medication).
3. In the conversation, respect the rabbi's domain (halacha, community life) and state yours (clinical assessment and treatment).
4. Agree who tells the client what, and report back to the client.
5. Record the consultation and consent.
Example language (illustrative, to a rabbi with consent): "[Client] asked me to speak with you. My role is the psychological treatment. He would like to know whether the exercises we plan are acceptable on Shabbat. I'm not asking for a ruling on anything clinical."
Watch for: the rabbi being asked to decide clinical matters, or the therapist to decide halachic ones; confidentiality creep; a rabbi's advice conflicting with safety. Escalate safety conflicts through supervision. It is working when the client feels the two authorities support, not compete with, each other.

4.10 Referral to Orthodox clinicians and culturally specific services

Purpose / when: when the client prefers an Orthodox therapist, when rabbinic leaders forbid secular clinicians, or when the presenting issue needs in-community expertise. NEFESH is an international network of Orthodox Jewish mental health professionals with a member directory. Services named in the RCA-related commentary include NEFESH, SINAI, OHEL and referral services, and some facilities offer kosher food and Orthodox staff. [source: NEFESH site; Schwartz 2016]
Steps:
1. Ask about the client's preference without assuming it.
2. Explain options (e.g. Orthodox clinician, secular clinician with consultation, faith-sensitive inpatient service).
3. Make a warm handover with consent, and offer continuity until the new clinician takes over.
Example language (illustrative): "Some people prefer a therapist from within the community, and some prefer someone outside it. Neither is wrong. What would suit you?"
Watch for: referring away because you are uncomfortable; or holding on to a client who wants a matched clinician. It is working when the client chooses with full information.

4.11 Responding to requests for directive guidance

Purpose / when: when the client asks you to decide, e.g. "Tell me whether it's right for me to get divorced." [source: Doron et al. 2024, quoting a client] Doron et al. describe a relationship that can mix dominance and dependence, and warn against cultural imperialism and directing life decisions. [source: Doron et al. 2024]
Steps:
1. Acknowledge that in the client's world, guidance from an authority is a normal way to decide.
2. Separate the questions: halachic ones go to their rav; clinical ones (e.g. safety, mental state) are yours; life choices are theirs.
3. Help the client clarify their own values, fears and options so they can bring a clear question to their authority.
4. If safety is at stake (e.g. abuse in the marriage), state your clinical view and safety duties plainly. [synthesis]
Example language (illustrative): "I can't make that decision for you, and I don't think I should. I can help you get clear on what you want and what you'd ask your rav."
Watch for: the client experiencing refusal as rejection; you sliding into giving the answer you prefer. It is working when the client brings their own view first.

4.12 Working with family and community

Purpose / when: when collective interests take precedence over individual concerns, when parents monitor sessions, or when distress is expressed through action ("The child acts out the thing rather than speaking the thing"). [source: Doron et al. 2024] Lashon hara (prohibited disparaging speech) can make clients reluctant to speak about others. [source: Doron et al. 2024] In ultra-Orthodox settings, patients are often accompanied by a chaperon (a relative or community member); chaperons can act as cultural bridges who ease the patient's discomfort with therapy and sometimes as active co-therapists. [source: Heilman and Witztum 1994, abstract]
Steps:
1. Map who in the family and community has a say in the client's care (CFI Social Network module). If a chaperon comes to sessions, agree with the client, alone, what role (if any) the chaperon takes and what stays private. [source for the chaperon role: Heilman and Witztum 1994; the consent step is synthesis]
2. With consent, use the CFI Informant Version with a key family member.
3. Agree what parents of a minor will and will not be told, within law and safeguarding.
4. Address lashon hara concerns directly. Ask whether the client would like to check with their rav what may be said in therapy. [synthesis]
5. With children and adolescents, attend to behaviour as communication and use developmentally appropriate methods. [synthesis]
Example language (illustrative): "I know speaking badly about others is a serious matter for you. Some people check with their rav about what is allowed to say in therapy. Would that help?"
Watch for: a family member speaking for the client; the client censoring all mention of conflict. It is working when the client can describe relationships honestly without feeling they have transgressed.

4.13 Routing medication and remedy questions

Purpose / when: when the client asks about stopping or changing a medicine, has been advised to by a practitioner, or uses folk remedies alongside medicine. Historical ba'alei shem combined holy Names and amulets with folk remedies (segullot). [source: Scholem, Encyclopaedia Judaica; Kohler and Ginzberg]
Steps:
1. Do not advise on starting, stopping or changing any medicine or remedy.
2. Encourage the client to tell their prescriber everything they are taking or have been advised.
3. With consent, inform the prescriber of any advice the client received that may affect treatment.
4. If the client wants a rabbinic view on medication, support them in asking their rav and their prescriber together. [synthesis]
Example language (illustrative): "That's an important question for your doctor. Would you like to raise it with them this week? I can let them know, with your permission."
Watch for: abrupt stopping of medicines; delay of urgent medical care. It is working when the prescriber is informed and the client feels free to tell both of you.

4.14 Integrating blessings, pilgrimages and other healing experiences

Purpose / when: after the client has received a blessing, visited a saint's tomb, received an amulet or been told the cause of their trouble by a kabbalist. Bilu and Abramovitch note therapeutic effects of saint dreams within pilgrimage. Bilu notes the saint's idiom helps people cope with life crises. [source: Bilu and Abramovitch 1985; Bilu 2009]
Steps:
1. Invite the client to describe the experience and what it meant, without asking for religious content you should not record.
2. Explore what changed (hope, guilt, relief, fear) and what they plan to do next.
3. Link helpful meanings to treatment goals.
4. If the experience increased fear (e.g. being told they are cursed), work with the fear clinically and support them in seeking a second view from their rav. [synthesis]
Example language (illustrative): "After the visit to the tomb, what felt different? How might we build on that here?"
Watch for: relief used to drop treatment; increased fear or guilt; financial exploitation. It is working when the experience becomes part of a coherent recovery story.

4.15 Safeguarding

Purpose / when: whenever there is risk of abuse, exploitation, harm to self or others, or delay of urgent medical care. The Royal Commission into Institutional Responses to Child Sexual Abuse (Case Study 22, Yeshiva Bondi and Yeshivah Melbourne) found that the way the concepts of mesirah and the discouragement of speaking ill of Jews or Jewish institutions were applied "strongly suggested" some community members were discouraged from reporting. Survivors who reported were treated as outcasts. The Rabbinical Council of Victoria's 2010 advisory resolution said mesirah does not apply to child sexual abuse and that reporting is an obligation under Jewish law. [source: Royal Commission Case Study 22]
Steps:
1. Follow your jurisdiction's mandatory reporting and your professional code. Religious authority does not override these duties.
2. If a client fears reporting is forbidden, acknowledge the conflict and tell them that rabbinic bodies have ruled reporting child sexual abuse obligatory. Offer support to consult a rav known to support reporting if they wish. [source: Royal Commission Case Study 22; synthesis]
3. Plan for community backlash: discuss ostracism risk and support for survivors and families.
4. Assess exploitation by any practitioner (large payments, secrecy, isolation, sexual contact, discouraging medical care) and report as law requires. [synthesis]
5. If a client asks for help harming others through magical means, explore the anger and assess risk of real-world harm. [synthesis; source: Harari 2010 on clients seeking harm]
6. Follow standard suicide and violence risk assessment, using religious protective factors and concerns as the client describes them. [synthesis]
Example language (illustrative): "What you've told me means I have a legal duty to make a report. I'll explain what happens next and stay with you through it."
Watch for: pressure from family or community to withdraw a disclosure; your own reluctance to report out of fear of damaging trust. It is working when the person is safe and supported, even if the relationship is strained.

5. Handling problems

All responses below are [synthesis] unless a source is given.

Client stops after one session because of stigma. Re-contact once, briefly. Offer a lower-profile option (telehealth, an appointment time when others will not see them) and the option of an Orthodox clinician. Name the fear of community exposure directly. [source: Doron et al. 2024 on stigma]
The rabbi forbids therapy with you, or with secular clinicians. Do not argue against the rabbi. Ask the client what they want. Offer referral to an Orthodox clinician (e.g. via the NEFESH directory) or, with consent, a conversation with the rabbi about your role. [source: Doron et al. 2024; NEFESH site]
Client wants you to rule on halacha or life choices. See 4.11. Separate the domains repeatedly and calmly.
Client attributes everything to ayin hara, a curse or a dybbuk and rejects clinical treatment. Explore the explanatory model fully (4.5). Look for overlap (e.g. both agree sleep and fear must improve). Offer treatment as compatible with, not instead of, their religious steps. If there is risk, or delayed urgent medical care, act on safety.
Therapist anger, irritation or fascination. Take it to supervision. Doron et al. report secular therapists' anger and distress, and also growth in humility and patience. [source: Doron et al. 2024]
Rupture after an inadvertent dismissal (e.g. a smile at a mention of amulets). Name it, apologise, and ask what it meant to the client. Ask again about the explanatory model.
Client is silenced by lashon hara concerns. See 4.12. Offer to work with feelings and their own experience rather than judgements of others.
Phoniness: over-using religious vocabulary. Speak in your own voice, and use the client's terms only where they carry meaning. [source: Doron et al. 2024]
Scrupulosity mistaken for piety, or piety mistaken for OCD. With consent, ask the client's rav what observance requires. Treat the excess, not the religion.
Exploitation by a practitioner. Ask about cost, secrecy and isolation. Support the client's own judgement. Where a crime is involved, follow reporting duties.
Family insists on attending, or monitors sessions. Agree a clear structure: some joint sessions, some individual, with confidentiality explained to all. [source: Doron et al. 2024 on parental monitoring]
Modesty and gender. Offer a same-gender clinician where possible. Avoid touch, including handshakes, unless the client initiates. Keep the door and setting arrangements acceptable to the client.
Language. For Yiddish- or Hebrew-dominant clients, use a professional interpreter or a clinician fluent in the language. Check the interpreter is acceptable to the client given community ties and confidentiality.
Marriage (shidduch) concerns. Discuss records, diagnosis labels and disclosure explicitly. Point to rabbinic efforts against "automatic disqualification" over psychiatric history. [source: Schwartz 2016]
Abuse disclosure with community pressure to stay silent. See 4.15. [source: Royal Commission Case Study 22]
Client asks you to provide an amulet, blessing, or contact with a kabbalist. Decline, explain your role, and help them bring the request to their own authorities.

Sources

Web sources:

Books and papers cited:

Rosman M (1996). Founder of Hasidism: A Quest for the Historical Ba'al Shem Tov. Berkeley: University of California Press. Revised paperback 2013, Littman Library / Liverpool University Press.
Bilu Y (2009). The Saints' Impresarios: Dreamers, Healers, and Holy Men in Israel's Urban Periphery. Academic Studies Press.
Bilu Y, Witztum E (1993). Working with Jewish ultra-Orthodox patients: guidelines for a culturally sensitive therapy. Culture, Medicine and Psychiatry 17(2):197–233. doi:10.1007/BF01379326.
Bilu Y, Witztum E (1995). Between sacred and medical realities: culturally sensitive therapy with Jewish ultra-Orthodox patients. Science in Context 8(1):159–173. doi:10.1017/S0269889700001939.
Bilu Y, Abramovitch H (1985). In search of the saddiq: visitational dreams among Moroccan Jews in Israel. Psychiatry 48(1):83–92.
Greenberg D, Witztum E (2001). Sanity and Sanctity: Mental Health Work Among the Ultra-Orthodox in Jerusalem. New Haven: Yale University Press.
Harari Y (2010). Practical Kabbalah in Israel. The text's running heads place it in the introduction of a book titled Against Evil Eye; editor and publisher [uncertain].
Garb J (2011). In Huss B (ed.), Kabbalah and Contemporary Spiritual Revival, pp. 117–140. Ben-Gurion University of the Negev Press.
Kleinman A, Eisenberg L, Good B (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251–258.
Lewis-Fernández R, Aggarwal NK, Lam PC, et al. (2017). Feasibility, acceptability and clinical utility of the Cultural Formulation Interview. British Journal of Psychiatry 210(4):290–297.
Gureje O, Appiah-Poku J, et al. (2020). COSIMPO collaborative shared care trial. The Lancet.
Ofori-Atta A, Attafuah J, Jack H, Baning F, Rosenheck R, Joining Forces Research Consortium (2018). Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial. British Journal of Psychiatry 212:34–41. doi:10.1192/bjp.2017.12.
Bilu Y, Witztum E, van der Hart O (1990). Paradise regained: "miraculous healing" in an Israeli psychiatric clinic. Culture, Medicine and Psychiatry 14:105–127.
Heilman SC, Witztum E (1994). Patients, chaperons and healers: enlarging the therapeutic encounter. Social Science & Medicine 39(1):133–143.

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