A short course for a non-professional can’t provide the necessary skills for diagnosis

D

uring a recent trip to Europe, I had the zechus of speaking with the rabbanim of a large yeshivah gedolah. The menahel, Rav Schvartzbaum, was a dynamic personality and an out-of-the-box thinker who was dedicated to helping his bochurim grow in Torah and yiras Shamayim. The fact that he’d scheduled a mental health seminar for us further made it clear that he wanted his talmidim to develop into emotionally-healthy young men.

While I was officially brought in to lecture about diagnoses and treatments of mental illness, the talk quickly became a free-range question and answer session about this talmid’s anxiety issue and that bochur’s focusing problem. But we created a lively, open atmosphere for questions and answers and enjoyed our afternoon together.

“This was great, Dr. Freedman. And this is why we have a mashgiach who took a course in CBT. Baruch Hashem, with him on board, we can address all of our problems and get high-quality care for our bochurim,” Rav Schvartzbaum told me before I left.

Rav Schvartzbaum was ahead of the game regarding mental health concerns. But he also needed to know that a yeshivah his size should have a trained professional on board. Today, experts believe one out of three bochurim will eventually develop a challenge with either a mental health or substance abuse issue at some point in his life.

“That’s a great start, kevod HaRav, but I’m not sure that’s enough,” I said, feeling a bit bad that I was bursting his bubble. “CBT — cognitive behavioral therapy — is a great treatment tool for many individuals. But a short course for a non-professional can’t provide the necessary skills for diagnosis, and the tools learned would only be applicable in specific situations.”

It seemed Rav Schvartzbaum had hoped I’d be more excited, and let me know that his mashgiach hadn’t just taken the eight-week course, but had also been to Bnei Brak to take an extra four-week course last summer.

It was most certainly a great thing for this mashgiach and a good start for the yeshivah, but mental health is more complex than a few courses.

“Kevod HaRav, I wouldn’t call myself a Gemara rebbi after sitting through a few zemanim with my chavrusa, so why would we expect mental health to be any different? Psychopathology — understanding how the symptoms of mental illness play out — isn’t something you learn in 12 weeks. It’s something you learn as part of formal training and over the course of completing professional licensure. Taking a course can be helpful, but sometimes it’s like bringing a fire-extinguisher to a four-alarm blaze.”

“I hear you,” the menahel nodded, “but what can I do? Our community doesn’t have anyone like that.”

It was something I’d heard many times, and a problem that required some serious thought. Sending community members for formal training and licensure was becoming acceptable even in more insular segments of the heimishe velt. There are even foundations that fund such educational grants, and government organizations that provide formal training for community members. I’d recently spoken with the leaders of a different European community about recruiting a social worker to move to their city for the sake of having a professional to help the kehillah.

As I shared these thoughts, Rav Schvartzbaum asked me a fair question: “Dr. Freedman, with no disrespect, is there really such a qualitative difference between taking a CBT course and learning how to be a social worker? I know plenty of terrible social workers who can’t make a diagnosis and I also know many trained rabbanim who can totally chap a matzav.”

He made a good point. I knew psychiatrists who’d lost their licenses for recklessly prescribing medications to patients they’d never even met, and psychologists who told couples to divorce based on multiple-choice questionnaires. But these were anomalies, and not an excuse for eschewing a formal degree in mental health.

“The most important part of a degree program is the training one gets in learning the signs and symptoms of mental illness, beyond learning basic therapies,” I said. “CBT is a great skill for treating anxiety disorders, just as EMDR can be helpful for certain trauma disorders. But understanding the fundamentals of history-taking, recognizing developmental and behavioral patterns, and the subtleties of psychiatric diagnosis is something you can only get from working with hundreds of patients under professional supervision. That’s something one only gets in a formal training program and the associated licensure.”

Rav Schvartzbaum nodded as he stroked his beard. “Dr. Freedman, maybe you can give me an example of a time something went wrong, something I can use in order to talk to people about bringing a professional to our community.”

Actually, I’d been involved in an episode the previous month in the Yerushalmi community of the menahel’s own chassidus.

I became friendly with the rabbi who supervised the kashrus at the coffee shop across the street from my building. One day he asked if I had a moment to hear a story. Apparently his cousin’s son had a terrible case of social anxiety that wasn’t getting any better even though a “very-respected heimishe therapist” was coming to the house to do CBT twice a week for the past two months. Meanwhile, the young man hadn’t left his parents’ apartment since the beginning of the zeman, and had dropped out of yeshivah and disappeared from even his best friends. To me, this sounded a bit more extreme than pure social anxiety, and so my friend the mashgiach scheduled a home visit for me to see the bochur. As soon as I entered the room I could see it: the paranoia, the social withdrawal, and the vacant look of schizophrenia.

“Oy!” exclaimed Rav Schvartzbaum. “And this therapist thought he was treating simple anxiety? He’s a crook!”

“Forget the wasted money on therapy,” I said. “The poor kid had been sick for a full zeman, and the longer a person waits without treatment, the harder it is for the treatment to facilitate improvement. But the therapist didn’t know any better — he’d never had diagnostic training and was trying to ram a square peg into a triangular hole. He may have been good with CBT but this case was fundamentally different. And the bochur is now hospitalized.”

“So what do I do?” asked Rav Schvartzbaum. “Do I just approach one of the local gvirim and try to convince him to sponsor a qualified, frum social worker for our community?”

“Why not? The community supports a sofer, a mohel, and a number of great rabbanim. You’ve got a Chinese restaurant and a pizza shop. Why not get a good social worker to move here too?”

“Just like that?”

“Listen, if you can cover tuition for a fellow with a young family, you’ll have a selling point right off the bat. Have him start with a few hours in your yeshivah, a few hours in the cheder each week, and you’ve got a job offer.”

Rav Schvartzbaum had already taken out his phone. “I’m calling the gvir now, before I lose my resolve. And I want you to tell our donor how vital it is to cover this social worker with free rent for a year. I want the fellow to move here by Pesach.”

Identifying details have been changed to protect the privacy of patients, their families, and all other parties.

Jacob L. Freedman is a psychiatrist and business consultant based in Israel. When he’s not busy with his patients, Dr. Freedman can be found learning Torah in the Old City or hiking the hills outside of Jerusalem. Dr. Freedman can be reached most easily through his website www.drjacoblfreedman.com

 (Originally featured in Mishpacha, Issue 798)