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Eliezer Witztum, MD Jacob T. Buchbinder, PhD Onno van der Hart, PhD Summoning a punishing angel:
"Treatment of a depressed patient with
dissociative features”
Eliezer Witztum, MD Jacob T. Buchbinder, PhD Onno van der Hart, PhD.
Dr. Witztum is a senior staff psychiatrist and Dr. Buchbinder is a staff psychologist with the Jerusalem Mental Health Center-Ezrath Nashim, Jerusalem, Israel; Dr. van der Hart is a staff psychologist with the Institute for Psychotrauma, Utrecht, Netherlands. (Copyright 1990 The Menninger Foundation) The authors describe their treatment of a 24-year-old repentant, extremely observant Jewish man with major depressive disorder who complained of persecution by a personal angel. The therapists initiated a culturally sensitive psychotherapy of the patient, enacting a ritual summoning of the angel that resulted in the angel's transformation into an ally. The authors discuss the relationship of the patient's symptomatology to pathological mourning, trance, and dissociation. They advocate the use of a strategic combination of culture-specific concepts with modern psychiatric approaches in similar cases. (Bulletin of the Menninger Clinic, 54, 524-537) Both traditional healing practices and modern psychotherapeutic approaches are based on a rationale or a healing myth that includes an explanation of illness and health, deviancy and normality (Frank, 1973). In traditional societies, the myth is compatible with the world view (usually religious) shared by the patient and the therapist. The traditional healer-a shaman, for example-makes a diagnosis by performing certain acts, and then offers a remedy that may involve drugs or the performance of specific symbolic acts and incantations. According to Frank (1973), the healing efficacy of these procedures lies in the patient's expectation of help and in the perception that the healer possesses a special healing power. Not only in traditional healing practices, but in all health care systems, including modern psychotherapy, explanatory models accepted by patients and practitioners alike guide the choice among therapies and therapists and cast personal and social meaning on the experience of sickness (Kleinman, 1980). A potential conflict exists when the patient belongs to a subculture or religious group with beliefs and explanatory models that differ substantially from those employed by practitioners in the mental health establishment. Psychotherapists can solve this conflict strategical y by adjusting to the world view of the patient (cf. Van der Hart, 1978/1983, 1988; Van der Hart, Witztum & de Voogt, 1988). Within the context of cross-cultural therapy, these therapists endeavor to help patients articulate their symptoms and solve their problems in the mold of the prevailing idiom and with metaphors from their unique cultural background (cf. Crapanzano, 1975; Good & Good, 1986; Obeyesekere, 1970). Elsewhere, we (Bilu, Witztum, & Van der Hart, 1990) have described the successful treatment, based on this approach, of an ultraorthodox Jewish patient by two secular therapists in a mental health clinic in Jerusalem. After being exposed t0 a terrorist attack, this patient developed posttraumatic symptomatology; including hallucinations of a demon who threatened to kill him. These hal ucinations appeared related to the patient's traumatic grief about his father's death in a traffic accident when the patient was 8 years old. Treatment included instructing the patient to use traditional incantations intended to keep the demon at a distance and metaphoric imagery work in which the patient moved from the desert (where the demon and his aides were threatening him) to an oasis called the "Lower Paradise" where he reunited himself with his father, a mystical experience that successfully concluded therapy for him. Here we report a comparable cross-cultural therapy from the same clinic. This patient also expressed unresolved mourning regarding his father's death in the idiom of his subculture: A personal angel appeared and ordered him to perform self-afflictive behavior. The two therapists (one an observant Jew) were equally able to join the patient's cosmology. Treatment combined a standard psychiatric approach, consisting of the prescription of psychotropic medication and supportive therapy, with a culturally sensitive approach in Bulletin of the Menninger Clinic, 54 (4), 524-537 (1990) Eliezer Witztum, MD Jacob T. Buchbinder, PhD Onno van der Hart, PhD which the therapists carefully entered the patient's mystical world and confronted the maladaptive aspects found there.
Case report
The patient
The patient, whom we shall call Ezra, was a 24-year-old married man who had been a
Jewish penitent for 2 years; he was brought by his brother to the clinic because 0f "bizarre behavior." During the previous 6 months, while Ezra had been immersed in studying the Zohar (the key mystical Jewish text), he had heard voices, had dreams in which his late father appeared as a threatening black apparition, engaged in ascetic practices such as frequent fasting, often visited the graves of Zaddikim (Jewish saints), and had ritually lit candles on these graves and in his house. All these symptoms and practices became more intense 4 months prior to his admittance to the clinic after the birth of his first child, a girl. Ezra appeared unkempt and was only partially oriented to place and time. His cooperation was minimal. His affect was depressed, but his formal thought processes were intact. The content of his thinking indicated auditory and visual hallucinations of a personal angel. Ezra also experienced nightmares in which he saw his father dressed in black with a sad, suffering facial expression. These experiences began after the birth of Ezra's daughter.
Born in Israel and of North African descent, Ezra was the younger of two boys. His
father had been a quiet, sad man who began to drink in midlife and became a chronic alcoholic; at home he drank himself to oblivion and often slept covered with his own vomit. One night 9 years earlier, his father had asked Ezra to bring him a glass of water and to stay by his side because he felt ill. Ezra, then 15 years old, brought him the water but refused to stay with him. The next morning the father was found dead. The boy felt guilt ridden and developed a depressive reaction. He subsequently started using hard drugs. When Ezra was 18, his older brother persuaded him to quit taking drugs and join the military service. After successfully finishing his duty z. years prior to admission, Ezra became religiously observant, married, and started praying for a son to name after his late father. During the pregnancy, he excitedly awaited the birth of this son. Ezra was shocked when the child was a girl instead of a boy. He began to hear a voice that he identified as belonging to a personal angel who, instead of protecting him, had come to punish him for the neglect that had led to the death of his father. The angel told him to afflict himself by fasting frequently and otherwise eating minimally, by abstaining from sexual relations, and by wearing old and tattered clothes. This self-affliction, the angel said, would eventually bring him forgiveness. Ezra also began to visit grave sites of Jewish saints, praying there for several hours at a time. At night he ritually lit candles in his house.
In the second session, one of the therapists prescribed a small dose of the antipsychotic
medication thioridazine (Ridazin, U.S. trade name, Mellaril), and started psychotherapy with the assistance of Ezra's older brother, a rabbi and a penitent of many years. Recognizing that Ezra's symptomatology was related to guilt-ridden pathological mourning, both the therapists and the brother explained that Jewish law forbids mourning a dead relative for longer than a year. The therapists asked Ezra to take an important step toward completion of his unresolved mourning by writing a letter to his father in which he asked for forgiveness and for permission to continue to live (cf. Van der Hart, 1978/1983, 1988). One week later, Ezra brought his letter to the third session and read it out loud while crying and trembling: Father, I just want to ask for your forgiveness and pardon. I know that I am to blame or your death, but 1 ask forgiveness. 1 did not know that this is how it would turn out I want to see you alive But only say, I forgive you." Until I see you alive I will not believe that you have forgiven me. I have an angel that helps me to afflict myself. Please appear to me I do not want to be reincarnated as a stone, and therefore I cry the whole night. I wait for the angel to teach me mystical secrets of the upper spiritual worlds. Then I will know that you have forgiven me. After writing the letter, Ezra reported that he felt slightly improved and slept better. However, he also reported the continuation of his self-affliction, his frequent visits to the Bulletin of the Menninger Clinic, 54 (4), 524-537 (1990) Eliezer Witztum, MD Jacob T. Buchbinder, PhD Onno van der Hart, PhD grave sites, and his ritual lighting of candles. The therapists told him that he was functioning as a person suspended between life and death. They stated that a personal angel should be protective rather than punitive. The therapists and the rabbi sought to improve Ezra's outer appearance, an action they believed could positively influence his inner world. Ezra complied with their request to remove his tattered, dirty jacket because they convinced him that such dress was inappropriate for a religious student. Finally, the therapists asked him to bring a picture of his late father to the next session. The therapists realized that Ezra was pursuing an ecstatic religious experience, which would signify to him that God had forgiven him. Only then would he permit himself to resume enjoyment and involvement in everyday life. At the fourth meeting, his brother reported that Ezra had taken off his dirty jacket for one day, but when his angel warned him that he would be reincarnated as a stone, he had resumed wearing it. Nevertheless, the patient showed some overall improvement. The therapists and the brother negotiated with Ezra and reached an agreement that he would have his coat dry-cleaned. Ezra then took his father's picture, stared at it with great intensity, and began to cry. The therapists asked him to investigate the angel's nature, in particular its name and intentions: Was the angel concerned with Ezra's benefit or was it just an evil spirit in disguise? At the fifth session, the therapists noted some deterioration in Ezra's condition. He was more afraid of the angel, and he refused to change or clean his clothing. After some negotiation, he agreed to remove his dirty coat following the upcoming "Ninth of Av," a Jewish day of fasting that commemorates several national tragedies. Ezra had been unable to ascertain the name of the angel, but said that it belonged to the inner circle of the angel Raziel. (This important angel, according to its name, is connected with the "mysteries of God:") Ezra added that he summoned his angel by lighting eight candles aligned in a specific geometric form and by reading a text from the mystical tract The Book of the Angel Raziel. This book is a collection of Jewish mystical, cosmological, and magical material, first printed in 1701 and reprinted many times because of the popular belief that the book protects its owner's house from fire and other danger (Dan, 1972.a). The therapists noted modest improvement in the patient during the sixth and seventh sessions. Ezra began to smile and made eye contact on a few occasions. However, he still rarely spoke. The angel had responded to this symptomatic improvement by ordering Ezra to initiate harsher ascetic practices, including reducing his food intake even more. In the eighth session, Ezra reported no change in his condition but added that he planned a pilgrimage to the grave site of the Holy Ari in Safed (Rabbi Isaac Luria, the 16th-century founder of a cabalistic mystical school) and to the graves of other saints in Tiberias. During the ninth session, he recounted his experiences from the pilgrimage; he had recited special penitential cabalistic prayers. Although the angel was still "deep inside," after the pilgrimage Ezra felt less frightened by its threats. Because the angel still insisted that Ezra's father had not forgiven him, Ezra felt compelled to continue the afflictions and to stop taking medication. However, the therapists and the brother were able to persuade him to resume taking his medication, to which small doses of clomipramine (Anafranil) were added to combat depression. Ezra appeared for the 10th session wearing a fancy new hat. He reported that the angel now wanted him to mourn the destruction of the Jewish temple in Jerusalem (70 CE*) rather than the death of his father. The therapists advised him that such mourning is practiced in Av, the preceding month. Ezra began to cry. The therapists then gave a positive interpretation of his behavior by saying that indeed the month Elul (the current month) was the proper time for self-reflection about deficiencies in one's spiritual condition. Now they had a sign that he was moving toward a normal life: Ezra realized that because he had been so busy mourning his father, he had neglected the appropriate mourning of the destruction of the temple during Av and the required soul-searching during Elul in preparation for the Jewish New Year and Day of Judgment. His brother reported that Ezra could concentrate better and that he had resumed his study of the Talmud, a compendium of generally legalistic and nonmystical material compiled during the 6th century CE*.Ezra studied alone, however. During the 11th and 12th sessions, Ezra's functioning had improved but, as ordered by his angel, he also practiced more self-affliction by eating less; and he still refused to take any medication. The therapists realized that they must confront the angel directly. Perhaps they ___________________ * "CE" stands for Common Era. Bulletin of the Menninger Clinic, 54 (4), 524-537 (1990) Eliezer Witztum, MD Jacob T. Buchbinder, PhD Onno van der Hart, PhD could summon the angel and order it to cease afflicting Ezra. The brother, excited about this possibility, accepted the suggestion that he and the two therapists could serve as a lay Jewish religious court of three for this purpose. They planned to enact the ritual procedure during Ezra's next therapy session. The therapists' intention was to reframe the modus operandi of the angel and to reach a modus vivendi, making the angel an ally and friend instead of a punishing agent. This intervention would accord with the patient's and his brother's subcultural beliefs. What actually happened during the ritual deviated from the therapists' design and expectations because the brother, who as a religious authority was head of the court, tried to exorcise the angel and rushed the ritual in that direction. He presumably felt that maintaining any connection with the angel might be deleterious to Ezra. Summoning the angel
Although-Ezra was late for the next session, the therapists and the brother decided to
proceed with the ritual as soon as Ezra arrived. The brother hastened to lock the door, turn off the lights, and close the windows and shades. The therapists understood that these actions served to transform the room into a setting conducive to the induction of a trance. Ezra set up his candles in the form of an 8-stemmed candelabrum. After he lit them, the therapists and the brother ceremonially stated that a Jewish court of three was formally constituted. Leading the ritual, the brother requested that one of the therapists read a formula from The Book of the Angel Raziel, which the patient used to summon the angel (a formula originally used to swear or adjure the king of demons not to cause harm or damage). During the reading, Ezra spontaneously began swaying, moving his body and head in an increasingly rhythmic, vigorous manner. While adding his own ecstatic singsong of a two-syllable phrase with increasing loudness and force, he seemed to enter a trancelike state. Suddenly he became quiet and informed the others that the angel was present. The atmosphere in the room was charged and thick. The brother was tense, and the therapists noticed that the patient had become vague and distant. The brother, obviously impressed, hurriedly stated that, on behalf of the court, he was ordering the angel to cease afflicting Ezra and to return no more for "good or bad"-not even to reveal mystical secrets. Ezra seemed stunned and confused because he was still ambivalent toward the angel. One of the therapists then explained to him that, from then on, the angel had no right to disturb him because the angel belonged to another realm. The brother, tense and emotional, told Ezra to blow out the candles in one breath, thereby ending the ritual. Ezra did so, and the court declared that Ezra was now a free man, under his own control. The brother hurriedly opened the shades and windows, and turned on the lights. He handed The Book of the Angel Raziel to the therapists, saying that Ezra no longer needed it. Ezra nodded in agreement. The therapists had planned to convert the angel from a punitive antagonist to an ego- supportive al y. However, the brother was determined to drive the angel completely away once and for all. Nevertheless, the angel behaved according to the therapist's expectations by returning infrequently in the role of an ally.
At the next session-the 14th-Ezra appeared smiling, and his brother reported several
significant changes: Ezra now ate normally, he had resumed sexual relations with his wife, and for the first time, he had played with his infant daughter. However, the angel had still appeared a number of times without being summoned and had instructed Ezra to study the Talmud, a nonmystical work, and to read from the cabalistic book Tikkunei Zohar Because Ezra still showed depressive affect, the antidepressive medication was increased 25 mg. During the 15th session, Ezra reported that the angel had not reappeared. His brother said that Ezra was functioning better at home, was more sociable, and took much better care of himself and of his appearance. At the 16th session, Ezra reported that the angel had appeared twice, both times only to praise his Torah study. Moreover, although Ezra's father had previously appeared in Ezra's dreams as a mournful old man in a black cloak, he now appeared dressed in white and bathed in light. The brother remarked that Ezra had chosen life, but was still saddened by the loss of his father. To elevate the soul of their father, the brothers were studying the Mishnah (a compendium of laws edited at the end of the 2nd century CE) and chapters from the mystical Zohar. Such studies are culturally normative for Sephardic Jews. The brother related that a memorial meeting would be held soon in honor of their late father, when the brothers would ritually celebrate the completion of their studies. The therapists now had objective indications that Ezra was working through his guilt and grief using normative rituals, and that he had forsaken his idiosyncratic, pathological behavior. In addition, the Bulletin of the Menninger Clinic, 54 (4), 524-537 (1990) Eliezer Witztum, MD Jacob T. Buchbinder, PhD Onno van der Hart, PhD therapists regarded the memorial meeting as an apt leave-taking ritual that would further aid the working through of the unresolved mourning. The brother was planning to move from Jerusalem to become head of a religious seminary elsewhere, and Ezra and his family planned to join him. However, 4 months later Ezra arrived at the clinic with his wife (the brother was abroad). Although Ezra's medication had been mistakenly stopped, he was not psychotic. He was neatly dressed and was oriented to time and place. His cooperation was good. His affect was sad, and his formal thought processes were intact. The angel had ceased to visit him. One therapist advised Ezra to take the antidepressant medication again, and he complied. After taking the medication for 2 weeks (75 mg/day), Ezra showed improvement over his former depressed state. A year after treatment ended, the patient remains stable. He dresses well and attends the religious seminary ful time with his brother. The personal angel appears rarely and then only as an encouraging ally.
Diagnosis and cultural aspects
A formal psychiatric examination indicated that the patient's symptom complex fits the
DSM-111-R (American Psychiatric Association, 1987) description of a major depressive episode with psychotic features: His mood was depressed; he showed markedly diminished interest in almost all usual activities; he had stopped eating and therefore had lost a good deal of weight; he exhibited psychomotor retardation, a strong feeling of worthlessness, and excessive, inappropriate guilt feelings to a delusional degree; and he had mood-congruent delusions and hallucinations associated with unresolved grief, accompanied by a sense of guilt and a feeling of deserved punishment. This manifestation was, in fact, the patient's second depressive episode; the first episode had occurred at age 15 when his father died. Ezra blamed himself for his father's death. At that time, he did not seek therapy, but instead tried to overcome his intense emotional pain by using hard drugs. The second episode occurred after the birth of a daughter instead of a son reactivated the patient's traumatic grief. At that point, his brother brought him to the clinic. The diagnosis of major depressive episode with psychotic features ignores some important aspects of the patient's symptomatology. The psychotic features involved not only his involuntary, spontaneous hallucinations of an angel; they also concerned his deliberately summoning and communicating with this angel. The patient appeared to be a highly hypnotizable subject, whose trance induction and summoning procedures were inspired by traditional mystical sources. Both spontaneous and deliberately evoked hallucinations involved trance states similar to hypnosis. Thus the patient's psychotic like experiences are reminiscent of the rare diagnosis of hysterical psychosis, of which high hypnotizability is an essential feature (Janet, 1898/19o8; Spiegel & Fink, 1979; Steingard & Frankel, 1985; Van der Hart, Witztum, & Friedman, 1989). Although we do not advocate a reintroduction of this diagnostic category, we stress the incidence of this feature in psychotic patients because it makes psychotherapy-especially hypnotherapy-the treatment of choice.
Possession and nonpossession trance
The patient's self-induction of a trance state similar to hypnosis can be analyzed using
Bourguignon's (1979) study of altered states of consciousness (ASC), the different ways of inducing them, and their use in various societies. She proposed dividing the supernatural explanatory model of ASC into two basic categories: possession trance and nonpossession trance. Possession trance involves the impersonation of another personality, while nonpossession trance characteristically involves imaginary interactions with one or more personalities, beings, or forces through the hallucinatory experience. The "trancer" (i.e., the one who experiences the trance) in a nonpossession trance (usually a man) sees, hears, feels, or interacts with one or more beings, or forces, through the hallucinatory experience. In contrast, the subject of a possession trance (usually a woman) performs and impersonates another personality. The trancer, who prepares for the experience by learning what to expect and how to interpret what is perceived or felt, initiates the nonpossession trance through a hypoglycemic condition induced by fasting, sensory deprivation, mortification, or drugs. Possession trance, however, is induced by drumming, dancing, crowd contagion, or, more rarely, drugs. During the relatively passive nonpossession trance experience, the subject receives instructions from the spirit, which he or she wil be expected to remember and subsequently Bulletin of the Menninger Clinic, 54 (4), 524-537 (1990) Eliezer Witztum, MD Jacob T. Buchbinder, PhD Onno van der Hart, PhD enact. In contrast, the actively performed possession trance will be followed by amnesia for the performance. From these descriptions, it is clear that this patient was experiencing a nonpossession trance: He was passive and receptive to the angel's admonitions, and he remembered them. In preparation for the trance, he fasted and isolated himself. He used rhythmic body movement and a repeated melody to induce the trance, and he used an incantation formula to summon the angel.

Pathological mourning
The patient's symptoms stemmed from unresolved mourning complicated by remorse.
The patient continuously blamed himself for his father's death. This self-blame was probably based not only on his guilt feelings about letting his father die alone, but also on previously cherished wishes to rid himself of his drunken father. Ezra initially suffered from depression, which he subsequently tried to resolve by using hashish and hard drugs, then with religious fervor, and finally through marriage and the expectation that he would have a son who could be named for his father. His mystical studies during this time seemed to be an attempt to purify himself, to spiritually obtain forgiveness, or to escape pain by instigating mystical experiences. The birth of a daughter shattered his hopes for achieving forgiveness for his supposed complicity in his father's death. Deep depression followed, this time accompanied by auditory and visual hallucinations of a personal angel who provided spiritual guidance and prescribed ascetic practices; Ezra also experienced painful dreams of his father dressed in black and appearing to suffer.
The personal angel as a cultural phenomenon
The patient's personal angel was similar in many ways to the traditional Jewish
mystical phenomenon of the maggid, and may have been inspired by it. The maggid (literally meaning one who relates," cf. 2 Sam. 15: 13) is an angel or supernatural spirit that, in mysterious ways, conveys teachings to scholars worthy of such communications. A maggid is thought to pass secrets to the cabalist, the student of Jewish mysticism, when he is asleep or awake. The maggid speaks through the student's mouth or induces automatic writing (Dan, 1972b). Probably the most important appearance of a maggid occurred to Rabbi Joseph Caro (1488-1575). There are some interesting similarities between his maggid and the angel that appeared to our patient. In his biography of Caro, Werblowsky (1977) emphasized the ethical and ascetic orientation of Cards maggid. Werblowsky regarded the maggid's presence as evidence of the rabbi's strict, guilt- ridden conscience. The maggid verbally lashed out at various sins Caro had committed. "Take no pleasure from this world; the maggid told Caro, and it prescribed ascetic avoidance 0f eating and drinking, and the adherence to fasting and self-flagellation. From a psychodynamic point of view, the appearance of the maggid might be explained as a culturally sanctioned projection of a harsh superego. Cultural y, the maggid embodies key fundamentalistic religious values and ideals. Through his mystical studies, our patient found in the figure of the angel a recognizable and cultural y sanctioned expression of his deep remorse.
The personal angel as a dissociative phenomenon
According to Werblowsky (1977), the phenomenon 0f the maggid is comparable to a
dissociative state, although the former is more complex. Lewis (1978) concurred with Werblowsky to some extent; he regarded Caro's maggid as a mild dissociation resembling a hypnotic state, and added that he hesitated to consider the experience pathological because Cards consciousness remained clear and his content and outlook were consistent with a nondissociated state and with a clear memory of the experience. "Taking his times, cultural setting and personal qualities into account, his conduct can be held . to be within the normal range" (Lewis, 1978, p. 15). Janet's (1889 / 1973, 1907/ 1965) definition of dissociation as the splitting off, separation, and isolation of certain parts of the personality (dédouble-ment de la personnalité offered a century ago, is as relevant today as it was then (cf. van der Hart & Horst, 1989). The dissociation often results from traumatic experiences, and the dissociated parts (or states) escape control and sometimes the awareness as well-of the habitual personality. Bulletin of the Menninger Clinic, 54 (4), 524-537 (1990) Eliezer Witztum, MD Jacob T. Buchbinder, PhD Onno van der Hart, PhD They begin to lead lives 0f their own and either take over the patient's behavior or coexist with it. In line with Werblowsky's theory, the former could be conceived of as occurring when the maggid is evoked and speaks through the person's mouth. A switch into the maggid state has then taken place. Janet (1898/1908) reported that the "devil" appeared in this way in his patient Achille. Interestingly, his patient's dissociative disorder was also based on extreme feelings of remorse. The existence of two personality states side by side occurs when the person hears or sees an angel -that is, hallucinates the angel's presence- as was the case in our patient. Both Janet and modern authors have linked dissociative symptoms and disorders to the experience of psychological trauma (cf. Putnam, 1985, 1989a, 1989b; Spiegel, 1988). Dissociative reactions occur in. the context of acute trauma as an adaptive process that provides protection and al ows the individual to continue functioning, although often in an automaton like manner (Putnam, 1989a). Dissociative states may be little more than traumatic imagery, that is, the unassimilated memories of traumatic events, but these states can also develop a sense of self. The latter condition is most dearly seen in patients suffering from multiple personality disorder (MPD) (Putnam, 1989a). Both phenomena seemed to exist in Ezra. His discovery of his father's death constituted a psychological trauma that evoked violent emotions, especial y feelings of guilt and remorse. Ezra's personal angel may be seen as a kind of alternate personality, comparable to those of MPD patients. However, unlike the alternate personality in MPD, the personal angel (like the demon in demonic possession) is grounded in normative subcultural beliefs in the existence of such supernatural beings.
The experience of the personal angel as hypnotic state
The patient's trance state seemed similar to the hypnotic state. Breuer (1895/1955)
and, more recently, Bliss (1986) stated that dissociations are basically self-hypnotic phenomena. According to Janet's (1889/1973) dissociation theory, however, high hypnotizability is based on the existence of dissociative states. Whatever the relationship between the two, recent research findings indicate that traumatized individuals tend to be highly hypnotizable (Bliss, 1986; Spiegel, Hunt, & Dondershine, 1988; Stutman & Bliss, 1985). Treatment The strategic therapy for our patient was essentially an experiment in combining two different approaches. The first approach was a traditional social psychiatric approach of diagnosis, medication, and support, and the second was a culturally sensitive approach that comprised a mixture of modern strategic treatment techniques with the use of the patient's own belief system. From the beginning, the therapists did not question the reality of the patient's hallucinations and his belief in the existence of a supernatural personal angel. Supported by the religious authority of his brother, the rabbi, they could focus on the basic problem of guilt-ridden pathological mourning and explain that Jewish law forbids mourning a dead relative for longer than one year. By emphasizing this injunction, the therapists and the rabbi motivated the patient to accept their guidance to complete his mourning. The patient reported that writing a leave-taking letter to his father and asking him for forgiveness and permission to live helped him to feel slightly better. As the continuation of the self-afflictions and related practices indicated, however, this writing assignment was insufficient to resolve all or most of his guilt feelings. In hindsight, it would have been better if the patient had been instructed to write-at a fixed time and place -a continuous leave- taking letter to his father, to be finished only when the patient felt he was ready to say good-bye to his deceased father and start living again. Such an assignment is especially effective for resolving ambivalent grief when the relationship with the deceased is conflicted and guilt feelings may dominate (cf. Van der Hart, 1988; Van der Hart & Goossens, 1987). Instructions to the patient to change his subjective sense of self by improving his outer appearance were based directly on Jewish tradition. The therapists originally believed that the patient's compliance in giving up his old, tattered jacket indicated substantial progress; that is, separating from this linking object signified a step toward leave-taking from his deceased father. But as the angel's continuing admonitions and the patient's ascetic practices showed, Ezra still harbored unresolved guilt feelings. The therapists then again joined the patient's idiosyncratic experiences and mystical beliefs-which many ultraorthodox Jews follow-by planning to directly confront the punishing angel in a ritual summoning the angel to the lay court. Although this ritual took a course different from the one the therapists Bulletin of the Menninger Clinic, 54 (4), 524-537 (1990) Eliezer Witztum, MD Jacob T. Buchbinder, PhD Onno van der Hart, PhD had planned, it nevertheless proved to be an effective way of treating the patient's dissociative experience. The patient and his brother were easily persuaded to participate in the summoning ritual because of its cultural congruence. However, the rabbi/brother took an unexpected course of action. Fol owing such modern therapeutic approaches as ego state therapy and the treatment of malevolent alternate personalities in MPD patients, the therapists had intended to discuss with the summoned angel its reasons for punishing the patient and then to negotiate a more benign influence. Attempts at exorcism are considered to be therapeutically contraindicated (Putnam, 1989a). However, this approach contradicts traditional Jewish law, which does not regard such entities as dissociated ego states but rather as malevolent supernatural beings that must be completely removed. For this reason, and perhaps because he was frightened by the presence of the angel, the brother/rabbi, as head of the lay court, hurriedly ordered the angel to immediately disappear and never return. Interestingly, the angel did return a couple of times in the benign way the therapists had hoped for. Treatment was eventual y successful in resolving the angel's psychological foundation, as well as the patient's remorse and mourning regarding his father's death. This case history illustrates that cross-cultural therapy conducted in a culturally sensitive way offers unique treatment opportunities. It supports the policy of strategically combining a culture-specific approach with modern psychiatric approaches in similar cases. As the course of the summoning ritual indicates, this report also shows that the potential conflicts between traditional religious approaches and modern treatment techniques, based on secular therapeutic myths, are not always easily bridged. Acknowledgment The authors gratefully acknowledge a grant from the Israeli Ministry of Immigrant Absorption to the second author which partially supported this study. They thank Yoram Bilu, PhD, for his helpful comments on an earlier draft of this article. References
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental
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