Value-sensitive therapy: learning from ultra-orthodox patients. Academic Article uri icon


  • SAMUEL C. HEILMAN, Ph.D.* ELIEZER WITZTUM, M.D.** This paper explores the issues that arise when psychotherapists and patients do not share a common value system. Using three case studies of ultraOrthodox Jewish patients who hold religious values and beliefs, the paper illustrataes and defines a strategy of "value-sensitive therapy." It argues for treating patients without demeaning or discounting their values and beliefs. Part of the process of therapy assumes that at some point in their encounter, both patient and therapist will share a common perception of what is wrong, what needs to be corrected, and how the latter can help the former in effecting that repair. Furthermore, behind this fundamentally cognitive assumption is yet another supposition: that they both hold a common value orientation about what would in fact be a satisfactory resolution of the distress that has brought the patient to the therapist.1 When, however, the therapeutic encounter takes place between healers and patients who do not share a common culture, either cognitively or affectively, and who also do not share common values, the entire course of the therapy-to say nothing of the character of the encounter-is influenced. Not only does this sort of incongruence change the symbolic matrix within which the therapy occurs, with the result that the patient and therapist may not be heading for the same goal and may not equally value or evaluate the outcome of the therapy as "successful;" but it also-perhaps more importantly-calls for a modification in the strategies for interaction.2 These modified strategies require both therapist and patient to find some common cultural ground on which to meet in order to enable them to "speak some common language." In most cases, this calls for the patient to learn and accept the standard metaphors of illness and therapy-"doctor talk." Moreover, it often also requires the patient to accept the therapist's "judgments concerning the desirability and advisability of various courses of action."3 Sometimes, as has been argued in the literature on the development of "culturally sensitive" mental health training (particularly in the context of those from the dominant culture treating those of a minority culture), it simultaneously calls for the mental health professional to reframe his or her diagnosis and try to perceive the reality of the situation not simply through the therapists' explanatory framework but also through the prism of the patient's cultural metaphors.4-6 When the divide across which the therapy occurs also not only defines different cultural realities but contradictory and clashing values, a cognitive comprehension of differences may be insufficient. The therapist must also pursue a therapeutic strategy that is sensitive to the patients' values, even when this seems to oppose commonly accepted therapeutic approaches, so that patients do not emerge from the encounter having not only been healed but also "converted" to a new set of values that undermine a sacred or social order that matters, deeply to them. Perhaps nowhere do these issues become clearer than in the case of an encounter between a secular therapist, trained in modern therapeutic methods, and a religious patient, bonded to a traditional community of believers whose heritage and folkways are incongruent with the values and cultural assumptions that most psychotherapists share. For such patients, therapy may be an encounter fraught with danger. In large measure this is because commonly there is the risk that, as Allen Bergin has articulated it, "therapists, as secular moralists, may promote changes not valued by the [religious] client or the community."7 Moreover, even if particular practitioners are determined not to promote such changes, the fact remains that, as Aponte and others have demonstrated, "values frame the entire process of therapy," and thus even religiously tolerant therapists, as they "establish criteria for evaluation, fix parameters for technical interventions and select therapeutic goals" may remain insensitive to and unable "to understand and maintain an empathic respect for patients' religious orientations and beliefs. …

publication date

  • January 1, 1997