Psychotherapy with patients of the opposite sex

By Nachum Binyamin Klafter, MD

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It is completely appropriate for an observant man to pursue this type of a career [i.e., in a medical field, despite the fact that he will come into regular contact with women], because this falls within the scope of saving human life. However, it is clear that each individual is required to decide for himself whether he is capable of overcoming temptation, and whether he will truly be able to serve for the sake of heaven. HaRav Shlomo Zalman Auerbach " (In Nefesh Avraham, Abraham S. Abraham, vol. 2, Yoreh Deah, p. 214)

The impetus for this essay is a letter written by Rabbi Yitzchak Zilberstein " to a psychiatrist who practices in Bnei Brak, Dr. Michael Bunzel, in which he recommends that limits, for the sake of tzniyut, should be placed on treatment by psychotherapists of patients of the opposite gender. The actual letter specifically addresses the clinic in Bnei Brak where Dr. Bunzel serves as an administrator. In addition, the actual content of the letter leaves to the discretion of the clinics administration precisely what those limits should be. However, Dr. Bunzel has taken it upon himself to publicize this letter as though it were a blanket psak halakha for Torah observant therapists around the world. I am concerned about the possibility that many young therapists in our organization will erroneously believe that they are prohibited from treating patients of the opposite gender. In contrast to Rabbi Zilbersteins advice to Dr. Bunzel, there is a long, well-established history of Torahobservant psychotherapists treating patients of the opposite sex. These therapists, who number in the hundreds, have done so for many decades, with full support and guidance from poskim who have very different perspectives than Rabbi Zilberstein about the ideal standards for tzniyut in ones professional work. Therefore, as such, this letter is not really applicable to the vast majority of Torah-observant psychotherapists. In this essay I will review the normative halakhic approach to psychotherapy treatment of patients of the opposite gender. This understanding is based on the approach which has been related to me by dozens of rabbis in Israel and in North America since I first started medical school 21 years ago. It is also based on the mentorship and guidance I have received from several observant, highly-experienced mental health professionals. I have divided the essay into three sections, in which I aim to do the following: 1. Review the relevant halakhic principles which underlie the established practice to treat patients of the opposite sex, which is followed by the vast majority of Torah observant psychotherapists. 2. Elucidate how these halakhic principles are fully applicable to the psychotherapy situation, including psychodynamic psychotherapies which intensive, long term discussions of emotionally charged topics. 3. Briefly discuss the trend in certain communities toward extreme stringency in gender separation, including an observation that excessive standards for sexual modesty have brought about an unintended consequence of lowering the threshold for sexual arousal, which in turn sexualizes stimuli that would be normally innocuous. * * * * * *

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1. Observant therapists and physicians have been treating patients of the opposite sex for many decades with full guidance from their rabbonim.

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There are two central, halakhic principles which form the basis for a presumption that professionals are capable of carrying out their professional duties with clients of the opposite gender while observing appropriate professional and halakhic boundaries. y (literally a professional is mentally preoccupied with his professional work), also referred to in the halakhic literature as . This principle states that there exists in the halakha a presumption that professionals in the course their work will maintain a professional frame of mind and will relate to their clients in a professionally appropriate manner. This is why physicians are permitted to examine female patients who are undressed, whereas in an ordinary, non-professional setting, the halakha forbids men from deliberating gazing at the female form. Although this reasoning behind principle is intuitive, its application to professional psychotherapy requires an understanding of the underlying halakhic prohibitions, which are not intuitive. I will therefore review the basic Talmudic and halakhic sources. (deterrence from transgression due to the fear of being caught): In general, the halakha recognizes that the risk of being caught functions as a deterrent to transgression. This important principle operates as a mitigating factor in many areas of halakha to allow for leniency. For example, in the kashrut industry, allows us to rely on intermittent supervision rather than full-time, constant supervision for certain types of food production. With professionals, this principle takes the special form of a specific legal presumption ( ) that professionals are ordinarily deterred from ethical violations because do not wish to harm their professional reputations or ruin their careers. Therefore, in the psychotherapy setting, the severe financial and legal consequences of professional boundary violations are an added factor, in combination with the laws of yihud and negiya, to mitigate concerns about the risk of sexual impropriety. This principle is cited by poskim as another basis to permit psychotherapists to work with patients of the opposite gender. This principle, which is intuitive, is not unique to Jewish Law. The same reasoning is employed in all societies by professional licensing boards which perform routine audits of licensed professionals for compliance with professional standards, as well as formal investigations in response to complaints. The principle of I would like to analyze some of the fundamental sources and concepts related to the principle of , which was the basis of the psak by Rabbi Naftali Bar Ilan which permits psychotherapy treatment with the opposite gender. This psak was shared with the Nefesh International organization by Dr. Seymour Hoffman. Dr. Bunzels criticism of Rabbi Bar-Ilans psak will serve as a good springboard for our discussion. Here is an excerpt from Dr. Bunzels email to our list-serve: I was shockingly distressed at the response that he received from his local rabbi which renders psychologists and counselors alike, as being "tarud" in their profession, like any other profession, be it medical or otherwise. I was even more astounded that there were no responses from practitioners around the world whose profession was reduced halachically to that of a technician. In other words, just as a plumber is busy with his profession and is not considered to be in a position to entertain unwanted thoughts, so, too a psychologist or mental health professional (I must state that I consider the characterization of Rabbi Bar-Ilan as his local rabbi to be inappropriate. Rabbi Bar-Ilan is actually an eminent authority in matters of psychology and halakha.) Dr. Bunzels critique of this psak is interesting, and deserves careful attention. His understanding of the psak is that Rabbi Bar-Ilan bases his reasoning on an inaccurately reductionistic view of psychotherapy. However, Rabbi Bar-Ilan does no such thing. Rather, Rabbi Bar-Ilan is correctly applying to

Klafter, Psychotherapy with Patients of Opposite Sex

psychotherapists the legal presumption of , a principle which applies to all professionals who work with clients of opposite gender. In other words, this is not a concept that applies only to technicians. Rather, it is applicable to all professionals, including doctors, nurses, lawyers, accountants, tailors, custom dress makers, scientists, and professors. Therefore, Rabbi Bar-Ilans psak does not indicate that he sees the work of a psychotherapist as being just as a plumber. Rather, it indicates that he considers psychotherapists to be professionals. (In fact, I do not believe this halakhic principle would be applicable to plumbers at all, as their professional work does not involve contact with potentially erotic stimuli.) Sources in the Torah, Talmud, and Shulchan Aruch There is a Torah prohibition against a man deliberately bringing himself into a state of sexual arousal (other than during permissible sexual activity with his wife). This prohibition is referred to in the halakhic literature as (You shall avoid every evil thing.) This prohibition is derived from a homiletic interpretation of the following Torah passage: -: : : When the camp goes out against your enemy, you shall guard against every evil thing. When there is a man among you who will be impure due to a nocturnal emission, he shall leave the camp and shall not come back inside the camp. The juxtaposition of these two verses is interpreted to mean that that one must avoid things which will lead to arousing sexual fantasies and which therefore may lead to an ejaculation. This is elaborated in the Talmud, in Tractate Avoda Zara 20a-20b: ): ' ? , ! , ( . : -. " : , , [ ] ): " ... :

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( , ,

One who sees beautiful people should say Blessed are You Who has created thus in His World. But to stare [at beautiful women], is that permitted? Here is a proof against that: And you shall guard against every evil thing. Meaning, that a man should not gaze at a beautiful woman even if she is single, or a married woman even if she is unattractive, or at the colored clothing of a woman, or at donkeys, pigs, or birds at the time they are mating... Our sages taught: And you shall guard against every evil thing. [This means] that a person should not indulge sexual fantasies during the day and come to impurity by night But according to your logic, this case which was taught by Rav Yehuda that it is permitted [for animal breeders] to directly manipulate the genitalia of animals as they matethey are obviously staring [at the animals as they mate. How then, can this be permissible?]! No, in that case [of animal breeders], they are preoccupied with their professional work [and therefore they will not become sexually aroused]. The Shulchan Aruch lists E.H. 21 and 23 lists various examples to illustrate the variety of situations man should avoid because of the high likelihood he may become aroused. I am quoting only the section directly germane to our discussion of leniency in such matters for professionals involved their work.

Klafter, Psychotherapy with Patients of Opposite Sex

, , ( , . ) . ,

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It is forbidden for a man to deliberately arouse himself sexually, or to indulge deliberately in sexual fantasies. Rather, if he begins to experience a sexual fantasy, he should redirect his mind from these matters to words of Torah, for She [the Torah] is a beautiful doe, a graceful deer (Proverbs 5:19) Therefore, one should not stare at animals or birds while they are mating. However, it is permissible for animal breeders to directly guide the genitalia of animals as they are mating, because since they are immersed in their professional work they will therefore not become aroused by sexual fantasies. Note the final sentence. It is ordinarily forbidden to stare at animals while they are mating because it is expected that this will lead someone to begin fantasizing about sex, and to therefore become sexually aroused. However this prohibition does not apply to professional animal breeders, because while they are involved in their professional work ( ) they will not become sexually aroused ( ). They are focused on his professional duties. Although the sources to do not say this explicitly, I would suggest that this principle is also based on the assumption that professionals have been significantly desensitized by their frequent and repeated exposure to such stimuli and situations in the course of their work. The example of animal breeders probably strikes most of us as rather odd, but this is because we live in twenty-first century high-tech urban and suburban communities. We are therefore disconnected from the sources of our food production, and are seldom around animals with the possible exception of a neutered household pet. We never see the mating of animals and we do not associate the sexual behavior of animals with arousing sexual fantasies. However, before industrialization and urbanization from Biblical times, through the Talmudic era, middle ages, and the period of the codification of the Shulchan Aruch, people were much more involved with the production of their own food, and had significantly more exposure to farm animals than we do. The rhythms of the life cyclemating, pregnancy, birth, development, aging, and death, were experienced at a very early age by children through their contact with animals. This is a likely reason why the Prophets and the Sages refer to animals in so many metaphors employed in the Tanakh and the Midrash. This also helps us better understand why the Talmud forbids deliberately observing the sexual behavior of animals. It is clear from the language of the Gemara, quoted by the Shulchan Aruch ( ), that the case of animal breeders is used to illustrate this halakhic principle because the Sages consider the actual manipulation of an animals genitals while they are mating to be an obvious situation in which lay persons could easily experience a cascade of sexual thoughts and fantasies. It is important to note that the halakha does not state, Therefore, one should not become an animal breeder. Nor does the Shulchan Aruch state, Although it is permissible to become an animal breeder, a pious individual should refrain from doing so ( ), a familiar formulation in many other areas of halakha. Despite a graphically sexual component to this work, animal breeding is a totally respectable career which serves the legitimate needs of the community. Rabbi Auerbachs remarks on the medical field quoted at the beginning of this paper express s similar attitude about the field of medicine. Deterrence from sin by the fear of being caught I will spend less time reviewing sources related to this principle because it is, as mentioned above, intuitive. Suffice it to say that there is a presumption ( ) in halakha related to which states the following: A professional will not do anything to ruin his professional reputation. This is stated in a several different ways: (see the Tzitz Eliezer below) and also

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(See Encyplopedia Talmudit v. 13, . ). These concepts stem from the halakhic principle of

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This does not mean that the halakha subscribes to a nave notion that there are no dishonest lawyers, or no doctors who commit sexual boundary violations. But what it does mean is that professionals, because their livelihoods depend on their reputations and their ability to maintain professional licenses, are ordinarily deterred from violating their professional codes of ethics. In the psychotherapy profession, there is no question that the most severe taboo is sexual boundary violations with clients. This halakhic principle is an acknowledgement that professionals are less likely to commit certain transgressions in the course of their professional work than they would be outside of the profession setting, because such transgressions can ruin their careers. It is an extra measure of deterrence to help fight temptation. It is obviously not a failsafe, but it nevertheless is considered a significant factor according to the halakha. Rabbi Moshe Feinstein, " : may treat the opposite gender is the basis for the established precedent that physicians

In a fascinating responsum, Rabbi Moshe Feinstein considers the case of an married man who, because he cannot ejaculate during sexual intercourse, is advised to procure his own semen in order to impregnate his wife via artificial insemination. The actual question is whether the husband, himself a physician, should be the one to perform the artificial insemination, and whether her niddah status would make a difference for this halakhic question. In the course of the responsum, Rabbi Feinstein discusses the general permissibility of physicians treating patients of the opposite sex. He is actually quoting an important ruling by the " which states that it is a universally accepted practice for Jewish physicians to treat female patients. Rabbi Feinstein then reveals that is the underlying halakhic principle which governs why this is permissible. It is worth noting that this ruling by the " states that the availability or unavailability of another physician is irrelevant to the established halakhic precedent that male physicians can treat women. , " " " , "

As far as the widespread practice that Jewish physicians examine the heartbeat of a woman, even a married woman or a Gentile woman, even though Gentile physicians are available, and they [the Jewish physicians] also perform other types of medical examinations in that case it is permitted for them even rabbinically because they are preoccupied with their professional work... Rabbi Eliezer Waldenberg, " : the opposite gender is a deterrent to sin for medical professionals who work with

The following is an excerpt from a lengthy treatment of the laws of yihud by the late Rabbi Eliezer Waldenberg, in Tzitz Eliezer, chapter 40. In this series of teshuvot, entitled , he reviews many leniencies regarding the issue of yihud for allowing physicians to treat patients of the opposite sex. In the excerpt below, , the fear that transgression will become known publicly and will ruin ones professional reputation, is cited as an underlying halakhic principle which contributes to the fact that doctors are permitted to treat female patients privately. : : ' " " " . , " " , " " . " (

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" . , , " . The opinion of Rabbi Gedalia Dov Schwartz, " In 2007, I was one of three invited speakers at a day-long conference for rabbonim in Chicago which was devoted to halakhic issues in mental health treatment. The event was sponsored by Nefesh Chicago in order to increase their awareness about mental illness and sexual abuse, to encourage Rabbonim to make appropriate referrals of their congregants for mental health treatments, and to help rabbonim negotiate their various challenges and difficulties commonly faced when counseling congregants and students. I spoke on Boundaries in Rabbinic Counseling. Elliot Pasik, Esq. spoke on the legal obligation of rabbis in Illinois to report sexual abuse to the police and child protective service agencies. The longest presentation was on halakhic issues relevant to mental health and mental health treatments, including psychotherapy. It was given by HaRav HaGaon Gedalia Dov Schwartz, who is undoubtedly one of the most experienced and knowledgeable Dayanim in the world. During this talk, Rabbi Schwartz issued many piskei halakha, and answered many questions by rabbonim about psychotherapists treating patients of the opposite sex. Specific psakim were cited regarding halakhot of yihud, which must be observed during therapy with the opposite gender. In other words, male psychotherapists certainly may treat women and female psychotherapists treat men, and there are clear and established gedarim (halakhic guidelines) for how they may do so. Rabbi Schwartz made no hiddushim. He cited many teshuvot from the greatest halakhic authorities of the 19th and 20th centuries. Rabbi Schwartz stated that the two central halakhic principles governing this issue are (1) , and (2) . The most important priority, Rabbi Schwartz explained, was that a patient who needs treatment should receive it from the most qualified professional to whom he or she has access. Since it is permissible to treat patients of the opposite sex, it is inappropriate to add another layer of interference with the referral process in light of the great difficulties patients face in overcoming stigma, and finding a professional who is affordable, who has time for a new patient, and with whom they feel personally comfortable. Finally, Rabbi Schwartz stated that if a particular therapist has problems with sexual arousal during therapy with clients of the opposite, this may represent an emotional problem which is impacting the therapists professional skills. Such a therapist is obligated, al pi din, to consult with a professional mentor and his or her own personal posek to determine whether it is necessary to curtail his or her professional work. Rabbi Schwartz clarified that individual cases like this do not change the halakha for everyone else, as professional psychotherapists are presumed to be capable of relating to their patients of the opposite gender professionally without violating boundaries or becoming sexually excited. I will add my personal comment that Rabbi Schwartzs lengthy presentation was truly a magnificent display of halakhic erudition, psychological and emotional sophistication, intellectual complexity, and wisdom. It is my regrettable sense that this type of balance has become increasingly rare. The opinion of Rabbi Naftali Bar-Ilan, " Dr. Seymour Hoffman, a supervising and practicing psychologist and author of the monograph, Menthal Health, Psychotherapy, and Judaism, practices shared a written psak by HaRav Naftali Bar-Ilan with the members of the Nefesh International organizaiton. The main legal principle cited in Rabbi Bar Ilans psak was . Rabbi Bar-Ilan concludes that psychotherapists in the course of their work are expected by the halakha to able to maintain a professional role and frame of mind. He also states in this ] .[ " " " , (

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psak that if a therapist does not observe professional boundaries, there is a halakhic obligation to steer patients away from such an individual. Note that Dr. Bar-Ilans application of these principles is identical with Rabbi Schwartzs. An important component of Rabbi Bar-Ilans written psak is the following: . " , , , ,

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According to Jewish Law, in this issue [i.e., the permissibility of working with clients of the opposite gender] there is no distinction between psychologists, social workers, physicians, physical therapists, teachers, or the like. . Review Article by Dr. Moshe HaLevi Spero A review article on this topic was written by Dr. Moshe HaLevi Spero (Assya Volume 8, ) which analyzes the same halakhic principles. He cites teshuvot and other halakhic literature, arriving at the same conclusions as Rabbis Schwartz and Bar-Ilan. His essay can be accessed here: http://www.medethics.org.il/articles/ASSIA/ASSIA8/R0081212.asp

Additional anecdotal evidence that normative halakhic opinions allow psychotherapists to treat patients of the opposite gender The OHEL mental health organization in Brooklyn oversees the administration of mental health services to many thousands of Torah observant patients by hundreds of Torah observant providers. The clinic consults with gedolei yisrael. The president of our organization, Simcha Feueurman, has an important position in this clinic. OHEL retains an official halakhic authority, Rabbi Dovid Cohen, a talmid chacham of international standing. Their therapists regularly see patients of the opposite gender. The same Rabbi Dovid Cohen serves as the official halakhic authority for our organization, Nefesh International. I have heard Rabbi Cohen answer many sheelot at the Ask the Rav sessions during our annual conferences. These questions have often involved cases of men treating women and women treating men. I have never heard him indicate that therapists should not work with patients of the opposite gender. Rabbi Cohen has also directly addressed questions about yihud during therapy and has ruled about the halakhic parameters. Again, there are halakhic guidelines which enable a therapist to treat patients of the opposite gender. At the annual Nefesh conferences, clinicians regularly discuss their work with patients, including those of the opposite gender. Rabbonim and observant clinicians are present and participate in these discussions. I have never heard a suggestion that such conduct is inappropriate. In Cincinnati, we have a Torah U-Mesorah affiliated girls high school which over a period of many years has referred students to observant, male psychiatrists (including for long-term psychotherapy). In addition, the Roshei Kollel of my community have referred female patients to me. They are musmachim of a major Haredi Lithuanian yeshiva, and seek the guidance of their manhigim on a regular basis. I am currently delivering a lecture series on mental health issues for the Orthodox rabbonim of Cleveland. It is sponsored by the Orthodox Mental Health Professionals of Cleveland. In my presentations, I have described many clinical situations, and I have clearly indicated that I work with both men and women as patients. None of the rabbonim has raised objections. It is also clear the rabbonim who are participating in this series (about 20 of them) refer congregants and students to the best therapists they are able to find, male or female (unless the referred individual makes a special request to be treated by a therapist of the same gender). Finally, all of us were trained in programs where working with the opposite sex was a requirement. There are therapists in the Nefesh organization who have been practicing psychiatry and psychology for two, three, four, and five decades. They have had thriving, successful practices for all of these years, treating patients of the same sex and opposite sex, following the piskei halakha of their rabbonim. These therapists have had relationships with the gedolei ha-dor, or with other rabbonim who themselves have regularly

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consulted with the gedolei ha-dor. Many of these therapists have been active in conferences of various professional and Jewish organizations, and have spoken publicly, often alongside rabbonim, and publish papers and books on mental health issues. This point was aptly expressed in a recent communication by Dr. Robert Lebovits, a Torah observant psychologist who practices in Pittsburgh, PA: I find it both curious and vaguely irritating to see halachic issues fundamental to clinical practice that were thoroughly examined decades ago being presented today as if no one had considered them before. Speaking for those of us who have been in the field long before it became widely accepted as a profession for a "good Jewish boy/girl", we too were greatly concerned with these shailos, asked our poskim, and received guidance from Torah authorities. Torah observant mental health professionals have been conducting themselves according to the guidance of halakhic authorities for many decades. The insinuation that they are doing something wrong and that all of their rabbonim have been providing them with faulty guidance strikes some of us as odd, and others as insulting. However, from a halakhic perspective, this letter by Rabbi. Zilberstein has the status for most psychotherapists of an unusually strict opinion given to an individual who resides in another community. In every area of halakha, there are authorities who issue unusually strict opinions. We are not responsible to follow such opinions, and we should not be concerned that they contradict the rulings of our own rabbis. * 2. * * * * *

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Application of these principles to psychotherapy

In this section, I will explain how psychotherapists work as professionals to help their patients develop a deeper understanding of their feelings and emotions in order to illustrate how the principle of applies in the psychotherapy setting. Not all psychotherapy modalities involve the same degree of close attention to the patients immediate emotions and feelings. Dynamic psychotherapies require the therapist to pay close attention not only to the patients moment-to-moment emotional state, but also to the therapists own emotional reaction to the patient. Therefore, dynamic psychotherapy will serve as a good for this discussion. Allow me to state my qualifications to make the following remarks about psychotherapy treatment and the therapeutic relationships. For over 11 years, I have served as a supervisor for numerous fully licensed psychotherapists locally, nationally, and internationally. For the last six years, I have served as the Director of Psychotherapy Training for a highly respected residency training program (University of Cincinnati), which includes the designing of psychotherapy curricula, supervising residents, and teaching classes in the technique and theory of psychodynamic psychotherapy. I am also a fully trained psychoanalyst and faculty member at the Cincinnati Psychoanalytic Institute, where I teach classes on psychoanalytic theory and clinical technique to advanced therapists who are training to become psychoanalysts. In addition, I have served on the Ethics Committee and Curriculum Committee of the same Institute. I therefore submit that my understanding of psychotherapy and the psychotherapeutic relationship consists of specialized knowledge which is greater than that of the typical psychiatrist, psychologist, clinical social worker, or counselor. Dr. Bunzel States the following: Yet, how can one compare this kind of work with the relationships created in the therapeutic framework where interpersonal dymanics and therapeutic alliance are an integral part of the relationship and crucial to treatment response. That is why I was disappointed in the response that Dr. Hoffman got from his rabbi In other words, Dr. Bunzel contends that that the therapeutic relationship is so fundamentally different than other professional relationships that it cannot be governed by the same halakhic principles which permit other professionals to interact with clients of the opposite sex. I believe that this represents a

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misunderstanding of interpersonal dynamics and the therapeutic alliance. relationship is, fundamentally, a professional relationship. The psychotherapeutic

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One might ask, Well, how often to therapists violate boundaries and become sexually involved with their patients? There is an entire literature devoted to this difficult question, and estimates of the rate of boundary violations fall between 1% and 6% of psychotherapist in North America. Experts on boundary violations believe that this is similar to other professions, and there is no evidence to suggest that this is any higher than sexual misconduct among medical doctors, lawyers, professors, accountants, or clergy. I would speculate that the rate of sexual boundary violations among Torah observant therapists is significantly lower than other therapists, but there is no data on this topic. Human beings experience feelings of anger, rage, sexual attraction, jealousy, love, and hatred in many types of relationships. A male lawyer who collaborates for many years with a female colleague is no less likely to form a close attachment to her than a therapist would with his or her patient. Psychotherapy is different from other interpersonal experiences because of the fact that in this setting, the patient is encouraged to think very carefully and talk very openly about such feelings. A female scientist is no less likely to become irritated at her Department Chairman than she is by her psychoanalyst. What is so different about the irritation she feels at her psychoanalyst is due the fact that her psychoanalyst has instructed her to talk about this irritation as openly as she is able, including any embarrassing or discomfort she feelings in revealing these feelings, and including the hurt or insult she imagines that her psychoanalyst may feel when he hears about this. Two other unique aspects of psychotherapy which are different than most real-life relationships are worth reviewing: y The therapy relationship is very asymmetrical. (i.e., the patient comes to the therapist for help and therapist provides it. The patient reveals his or her innermost feelings and secrets, and the therapist does not.) y Patients may feel more deeply understood by their therapists than they have ever have by others in life. The result of this unusual and contrived situation is that patients may develop a particular type of feelings toward their therapists. For some patients, these feelings are reminiscent of the feelings that children experience toward their parents. This may include a mixture of idealization and vulnerability. This idealization was referred to by Freud as the unobjectionable positive transference. Kohut considered this idealizing transference in narcissistic patients to represent an important step in restarting their stunted psychological maturation. Other patients may resent the relative power asymmetry between patient and therapist, and develop feelings of competitiveness or even hostility. And there are additional patients who may be deeply engaged in therapy and appreciate the professionalism of their therapist, but who on a conscious level do not develop remarkable emotional reactions toward the psychotherapist. The following example will illustrate how a therapist works with the feelings of the patient, and his or her reaction to them, as a professional. This is a summary of the psychotherapy process between an excellent female therapist, for whom I serve as a supervisor and her male patient: A 37 year old unmarried man has had very sparse romantic involvement with women, and is embarrassed about the fact that he is still a virgin. He explains that most women find him boring. The patient attends appointments twice weekly. As the weeks pass, the female therapist is bothered by the patients apparent lack of enthusiasm. It seems to her that he is not very interested in their work. She feels as though she is not engaging enough for him and wonders to herself, Why cant I seem to get him interested? Sometimes, during appointments with this patient, she feels inadequate as a therapist. She also feels insecure presenting this case material to her supervisor, and imagines that her supervisor will think she is lame or useless as a therapist. As the treatment continues, the therapist begins to understand that the patient is inaccurately reading criticism into her comments. The therapist microscopically examines, together with the

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patient, moments in therapy where he feels criticized. She shares her new understanding with the patient of how the fact that he imagines she will find him boring, inhibits him from sharing this thoughts and feelings; he therefore acts in a manner that causes her to feel that he is unengaged and uninterested. They are able to analyze this repetitive pattern of between the two of them, and how it resembles what is happening in the patients actual social interactions outside the therapy setting. They repeatedly analyzing his reactions to the therapist and discuss the parallels to his real-life relationships. He begins to understand that his shyness around women is actually related to a fear of rejection, and that it is causing him to act in such a way that women think he is uninterested in them. Over time, as the patient becomes more aware of how his behavior is perceived by others, and how the criticism he anticipates is largely a figment of his imagination, he becomes more social engaging and outgoing, and more capable of expressing romantic interest in women. This therapist worked in a psychodynamic modality, and therefore deliberately focused on her subjective sense that the patient seemed to be uninterested in working with her. In order words, she made an effort to be aware of her feelings toward the patient. The patient, himself did not realize that he was acting in an off-putting, aloof manner. The therapist was able to find moments in the therapy when the patient seemed to become even more reticent or aloof, and ask him to share his feelings and to consider what he might be reacting to. Because this pattern was repeated between patient and therapist, the patient became aware of his emotional reactions in an emotionally-immediate manner, which enabled him to take steps toward changing this pattern. This case also illustrates the commonly observed phenomenon of parallel process, in which the therapist experiences feelings toward the supervisor which are reminiscent of the feelings the therapist feels toward the patient. Such phenomena have been noticed, discussed, and written about by psychotherapists for nearly a century. Psychotherapists who regularly work with transference and counter-transference feelings are very much analogous to dermatologists who need to see the patients entire naked body to make a proper diagnosis of a rash. Their professional work involves close inspection of human feelings rather than close inspection of human skin. Competent psychotherapists work on a daily basis with such feelings without becoming sexually aroused, and without violating professional and ethical boundaries. This is how the concept of applies to insight-oriented, psychodynamic psychotherapy treatment. The psychotherapist, a professional who helps patients understand their feelings and emotions, is accustomed to working with such emotions as a professional.

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* 3.

The trend toward extremely stringent standards of sexual modesty and gender separation.

Chazal instituted safeguards against how men and women can interact: the prohibitions of yihud, negiya, and histaklut. These are guidelines for how men and women can interact with one another in private and in public places. In other words, the Sages did not prohibit men and women from interacting in public or private. They instituted guidelines for how they may interact in public and private. They did not institute mechitzot on buses, separate sides of the street for men and women to walk, or separate hours for men in women in supermarkets. In fact, in the Talmudic passage quoted above, it is clearly expected that men and women will interact with one another in public places, and a man is expected to notice a womans attractiveness. For such an occasion the Sages have written a brachah. I certainly do believe that there is less adultery in communities which observe yihud, negiya, and modest dress. However, I highly doubt that there is less adultery in communities where the public busses have mehitzot, where women are not permitted to drive cars, and where supermarkets have separate hours for men and women. Let me be very frank about what I am saying: I do not believe that there is any less adultery occurring in Williamsburg and New Square than there is in Teaneck and Riverdale.

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I have spoken to therapists who work in the Hassidic communities of Monsey, Williamsburg, and Boro Park, and I have been surprised to hear these therapists express the same distinct impression about the consequences of the extreme measures which have been implemented in their communities to enforce gender separation: These severe standards for tzniyut and gender separation have lowered the threshold for sexual stimulation, which has led to an increase in sexual problems. These therapists assert that, compared to the same communities twenty years ago when standards for modesty were less severe, there is now an increased frequency of sexual obsessions, compulsive masturbation, compulsive viewing of pornography, vaginismus, unconsummated marriage, and forbidden sexual behaviors including adultery and homosexuality. This is not a scientific epidemiological survey, but I nevertheless believe that the anecdotal judgment of these therapists is significant and compelling. How do stricter standards lower the threshold for sexual stimulation? Lets go back to 1970, when the typical Orthodox man in Boro Park might consider the sight of a womans thigh to be sexually provocative. By 1990 it had shifted to a womans ankle. Now, in 2012, some Orthodox men feel uncomfortable even seeing a woman on a bus or in the same room. What, exactly, are we accomplishing by implementing these extreme measures for gender separation? Before about 1990, I believe that the ideal model of a Ben Torah was a man who, when interacting with women, would exert tremendous effort to think about and relate to women in the most dignified and respectful manner possible. Now, 22 years later, I believe that ideal image of a Ben Torah has changed. In some communities it is now considered a meritorious sign of piety to say, I am an animal, and I cant control my sexual urges. Therefore, I really need women to sit at the back of the bus. In a responsum dealing with the inevitability of seeing and coming into contact with women in public places, Rabbi Moshe Feinstein (Even Ha-Ezer 2:14) rules that one should be capable of riding on buses or subways in close contact with women without becoming sexually aroused. He adds, that an individual is not capable of doing so without becoming sexually stimulated would indeed be obligated to avoid being around women, but would also be obligated to take steps to change himself because such a constitution is simply unacceptable:

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Therefore, there is no need to refrain from traveling on subways and buses during rush hour, when people are crowded together, even if it is impossible to avoid physical contact with women. This is because contact without intent for pleasure that results from the inevitable crowding and pushing is not done in an affection or licentious manner. Similarly there is no prohibition, for this same reason, to sit next to a woman when there is no other place available, because this is also not done in an affectionate or licentious manner. However if one knows that he will experience arousing sexual thoughts, then he should refrain from commuting if it is not absolutely necessary. But if he absolutely must travel in such a situation because in order to get to his place of work, then it is permitted for him from to do so even if [he will experience sexual thoughts]. But he must fight to divert his mind from such thoughts, and instead think about words of Torah, as the Rambam advises (Issurei Biah 21:19), and he can rely on this and continue to travel to work. However, if one knows that he has a lustful nature and that he will become

Klafter, Psychotherapy with Patients of Opposite Sex

sexual aroused then it is prohibited even if he needs to travel on the buses and subways for his job. But Heavan forbid that a person should be that way. This is a result of idleness. (Kesubos 49, about a woman, which applies equally to a man.) Consequently one needs to be involved in Torah study and work, so as to no longer be like this. I would argue that, gender separation, when it becomes too extreme, causes an imbalance in the locus of control from internal to external. Rather than asking an individual to adapt to his environment, we are manipulating the environment to reduce struggle in the individual. With such an approach, we no longer aim to produce a community of pious persons. Rather, we are striving to engineer a community where men simply never see women. Of course, this results in young men who have never learned how to interact respectfully with women. They are not engaged in academic discussions in school with girls. They are not waiting in line with girls in the cafeteria. In such communities it is also considered inappropriate to have men sit at the shabbos table with their sisters-in-law, or for boys to visit with their female cousins, even while chaperoned by their parents. Therefore, they do not have the experience of socializing with their female cousins. No wonder the very sight of a woman in the same room has become sexually provocative! It has been suggested to me that perhaps Rabbi Zilbersteins advice is appropriate for a therapist who lives in the type of Hassidic or Haredi community where such efforts are made to prevent any interaction, public or private, between men and women. In my opinion, Haredi therapists are professionals like any other therapists, and are capable of maintaining professionalism in all aspects of their work. But, in the spirit of Rabbi Auerbachs advice for individuals considering a medical career, I believe that ultimately we must ask each therapist to decide for oneself.

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