Psychotherapy and Teshuvah

A traditional perspective.

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Reprinted with permission from "Psychotherapy and Teshuvah: Parallel and Overlapping Systems for Change,"  Torah U-Madda Journal, Vol. 11 (Yeshiva University).

People come to mental health treatment because they are in pain. The presentations of their pain vary--they come because they suffer from symptoms that restrict or threaten their lives, because they struggle with inner conflicts that undermine and torment their integrity, or because if they don't come, they will lose their job, their spouse, or their children. 

Seeking Change

People seeking mental health treatments desire change in either outlook or behavior that will result in the removal of their pain. Most people who seek mental health treatment understand--or quickly come to understand--that the alleviation of emotional pain requires active participation in a process that involves understanding the reasons for their suffering and making concrete changes accordingly.

brain puzzleTeshuvah, repentance, can be considered a Judaic analogue of the process through which one's emotional pain is linked with the requirement and inevitability of change. In teshuvah, the change takes the form of eradicating delinquent behavior according to the precepts and ideals of Jewish law.

Indeed, observant Jews who believe in a religiously ordered cosmos accept the responsibility to fulfill 613 commandments, mitzvot. Transgression of any of these commandments constitutes wrongdoing that the offender is obligated to correct. The observant Jew who commits a transgression presumably feels pain and perhaps guilt, reflecting a disturbance in his/her proper orientation in God's creation.

Powerful Processes

The religious prescription for teshuvah constitutes, according to many authorities, a mitzvah in its own right. Teshuvah includes several components--confession to God, remorse, restitution, and the capacity to act differently when placed in the same circumstances, including, inter alia, the same temptation.

Teshuvah is a profoundly powerful moral goal in and of itself, in part, no doubt, in recognition of how difficult change can be, even if it is motivated by pain or guilt. The process of teshuvah is largely outlined in various halakhic [Jewish legal] texts where different sages address the nature of the transgression that has been committed.

Sins against one's fellow man, for example, require that specific behavioral restitution be made. Teshuvah following theft, therefore, can only be accomplished after the stolen property has been returned.

Like psychiatric treatment, the process of teshuvah is optimally performed when a person expresses a desire and commitment for change. The individual engaging in teshuvah has a well defined idea of the deficiencies that must be corrected and a relatively clear picture of the optimal end result.

Varying Methods

In contrast, in psychiatric treatment, the unfolding articulation of what needs to be changed or better understood is often the transformative component of the treatment. Indeed, psychiatric treatment begins with a clinical interview, a highly specialized dialogue between therapist and patient. The therapist sits with the patient and invites him to reveal his misery: "Please, tell me what brings you here."

Most therapists will agree on the diagnosis, or the proximal cause of the suffering. The therapist's specific orientation, the theory of human behavior to which she subscribes, however, will determine the clinical formulation, along with suggestions of treatment options.

Mental health treatments span the gamut from "talking cures" that delve into the distant past and explore the present situation, to those more strictly focused on cognitive/behavioral goals. Individual, family, or group therapy may be advised. Mood altering medication might also be prescribed.

Teshuvah and psychotherapy recognize that people suffer from feelings and behaviors which they are capable of changing. We begin our discussion by reviewing the frames of reference that underly the prescribed restorative and transformative processes of teshuvah and psychotherapy.

Finding the Right Path

Observant Judaism posits a clear frame of reference as to what the proper path in life is. Torah is the blueprint. Failure to adhere to this derekh [path] results in dislocation and pain. The mitzvot constitute the template for proper behavior, and teshuvah offers an authoritative way back from wrongdoing. Conflicts occur when individual desire goes outside the system.

Psychiatry is less unified in its frame of reference for achieving its goal. There are many models of the mind and a smorgasbord of methodologies to chose from. Hence, clinicians' diagnoses and treatment depend on their orientation.

There is no universally agreed upon organizing theory, and therefore, it is far more difficult to know which behaviors are "right" or "wrong." Rather, these constructs are derived on the basis of whether they cause or relieve pain, or increase pleasure. This lack of absolutes can be experienced as liberating and/or threatening. Regardless, this point probably constitutes the most salient difference between the process of psychotherapy and teshuvah.

Transference and Insight

Another point of divergence is teshuvah's notion of transference. Since the process of teshuvah operates fundamentally between man and God, the absence of a human collaborator can make emotional restitution a difficult, lonely task. In contrast, psychotherapeutic work deliberately cultivates the relationship between therapist and patient so that it may serve as the primary template for change.

The goals of insight oriented psychotherapy vs. teshuvah may also differ. In teshuvah the goal is not to end one's pain, but to alter one's behavior. Pain relief may occur as a secondary benefit.

In classical psychotherapy, the diminution or cessation of suffering is the goal. Insight, behavioral change, and medication may be employed separately or in combination. Theoretically, insight should lead to pain relief. Resultant behavioral changes are useful insofar as they maintain a better functioning system and prophylax against future suffering.

Cause or Effect?

Teshuvah posits that appropriate behavior will pave the way for higher level understanding and transformation of feeling states. Cognitive-behavior therapy, which works to correct habitual negative self-perceptions and other cognitive distortions agrees with this point of view. Classical psychodynamic psychotherapy, however, posits the reverse--properly harnessed insight will motivate correct behavior.

It is important to emphasize that there are many forms of psychotherapy, and that we have presented these processes in a simplistic form for the purposes of discussion. Our intention is not to provide a precise analysis of the processes involved in either psychotherapy or teshuvah, but rather to provoke some discussion about how these two processes may work in tandem, or at variance, with one another.

This articulation is particularly important in light of the fact that there are numerous rabbis who are involved in pastoral counseling, as well as many religiously observant clinicians who often feel caught in a dilemma of how to honor the patient's goals, even if those goals clash with the therapist's moral code.

Practical Application

A clear understanding of the principles and practices of teshuvah and psychotherapy is valuable to rabbis providing pastoral counseling as well as to psychotherapists treating frum [religiously observant] clients because it will facilitate more honest and ethical negotiations with persons seeking help.

Indeed, it is particularly important for clergy and religious educators to understand and disclose the nature and limits of the work they can offer a person seeking to reduce their pain in a therapeutic process with them.

At the core of this discussion is the idea that, for a religious Jew, the process of psychotherapy might fill a different need than that of teshuvah, but that there may be a real need for an individual to engage in both processes at different times in their lives. Therefore, there is a need for a greater collaboration between religious leaders and mental health professionals to ensure a deeper understanding of these processes and the ways in which they work to reduce human suffering.

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Dr. Michelle Friedman

Michelle Friedman, M.D. is Assistant Professor of Clinical Psychiatry at the Mount Sinai School of Medicine and Director of Pastoral Counseling at Yeshivat Chovevei Torah.