Jewish teachings and beliefs about depression

The aim of this study was to explore whether and, if so, how Jewish teachings influence strictly orthodox Jewish beliefs about depression. The rabbinic literature was searched for Jewish teachings relevant to depression. Ten consenting strictly orthodox Jews were purposively selected and interviewed using a semi-structured interview schedule focussing on their beliefs about causes of and treatments for depression. Thematic analysis was used to analyse transcribed interviews and explore relationships between community beliefs and the Jewish teachings identified in the review. The key themes in both the rabbinic literature and the community included the overriding importance in Judaism of preserving life, using appropriate, acceptable means to do so, and obligations to help others. Contrasts between rabbinic teachings and community beliefs included community concerns about stigma, generally lacking in the rabbinic literature, and greater rabbinic emphasis on spiritual exertion in dealing with depression. Findings could prove useful to those managing depressed, orthodox Jews.

Introduction

The strictly orthodox Jewish community in London, Israel and elsewhere lives with close rabbinic guidance, and lifelong study of religious teachings is widely practised (e.g., Greenberg & Wiztum, 2001; Loewenthal et al., 1995). What impact might such study have? This study looks at beliefs in the strictly orthodox Jewish community about the causes and treatments of depression, comparing them to views in the rabbinic literature. Do community beliefs show evidence of being similar to those in the rabbinic literature? In what respects? And if there are differences, in what respects, and why? How might beliefs about depression affect interaction with sufferers from depression? One issue of interest is whether the emphasis in hasidic teachings on joy (e.g., see Schatz-Uffenheimer, 1993, pp. 93-110) is reflected in community attitudes.

The rabbinic literature on depression

Search methods involved, in addition to electronic searching of relevant literature, manual identification of books covering Jewish medical ethics and law in Jewish and university libraries, searching them for teachings applicable to depression. Further, much information relevant to Jewish teachings was obtained by manual searching in relevant libraries. This section identifies salient themes in the rabbinic literature on the nature and causes of depression, as well as ways of coping, treatment and help-seeking. It was noted that the distinctions between guilt, sadness, melancholy and depression are not sharply drawn in the rabbinic literature, though there are extensive discussions of all such states. Causal factors: Two broad groups were identified. Firstly, sin (personal failings), and secondly, external events (stressors). However, although depression may be a result of the perception of personal failing, it can act as a spur to improvement. Additionally, depression itself can be seen as a failing, to be avoided, detracting from the joyful service of G-d. For example Schatz-Uffenheimer (1993, pp. 91, 95, 102) quoted the “hasidic imperative . . . never to despair, be sad or be regretful,” even over past sins, as this could cause “the fundamental sin of interrupting one’s service” to God. “Sadness is a great sin in Hasidism . . . Surrender to despair means surrender to the Evil Urge.” Lamm (1999, pp. 388-389) pointed out that “depression, which ostensibly spurs one to repentance, can undermine the confidence required for self-mastery.” However, Rabbi Nahum of Tchernobil (cited in Buber, 1975, p. 173) comforted his disciples who “had fallen prey to darkness and depression,” unable to pray although wanting to, that those “who truly desire to come close to God, must pass through the state of cessation of spiritual life and the falling is for the sake of the rising.” Schindler (1990, p. 34) pointed out “The Piazesner Rebbe operates within the perspective of the Baal Shem Tov that sees suffering (often caused by depression) as offering man an opportunity to rise or fall.” Coping: Suffering and/or personal failings may lead to depression, sorrow and guilt. These may be combated by a range of methods. For example suffering “leads to repentance, prayer, salvation and gratitude,” and “it is precisely in suffering that one should respond with joy,” since it “may have the effect of enhancing devekut,” which “represents the ultimate in joy . . . [enabling him to] contemplate the holy spark hidden within suffering . . . then will the . . . suffering cease” (Schindler, 1990, pp. 32-34, describing the teachings of the Piazesner Rebbe). The list of coping methods above - repentance, prayer etc. - are cognitive and emotional. Maimonides (1975 translation, pp. 28-29, 73) recommended a strategy involving some behavioural as well as cognitive components, indeed with features resembling contemporary cognitive-behaviour therapy: “A man shall habituate himself in these (desirable) character traits until they are firmly established . . . Time after time he shall perform actions . . . repeat them continually until performing them is easy . . . and (they) are firmly established in his soul.” Maimonides also recommended a temperate life, which involved healthy eating and exercise, music, poetry, paintings and walking in pleasant surroundings, as ways of promoting well-being. Hoffman and Hacarmi (2000, pp. 186-187) emphasised how Rabbinic teachings indicate that “action retrains behavior and thought.” Prayer and religious study are widely encouraged, with many rabbinic authors placing particular emphasis on the reading/recitation of psalms. For example, Witztum et al. (1990, p. 128) emphasised the value of the Hattikkun Hakkelali, “a collection of Psalms dealing with man in distress . . . both a clinical tool and a poetic work.” Rabbi Menachem Schneersohn, the late Lubavitcher Rebbe, advised the importance of: “strengthening oneself in the three areas of Torah study, prayer, and performing acts of lovingkindness” (cited in Wineberg, 2007, pp. 44-45), to “fight depression as a blood sworn enemy . . . run from it as you would run from death itself” (Wineberg, 2007, p. 114) and “increasing your diligence in Torah study . . . We must completely distance ourselves from atzvus (sadness) and marah shechorah (black bile - i.e., melancholy) . . . If one cannot achieve this, one can accomplish it by not thinking about oneself but about G-d.” A further important method is to be deliberately joyful: “I have advised you not to be sad and depressed . . . The verse (Tehillim 100:2) exhorts us: ‘Serve G-d with joy’. For man’s joy [in the lower world] draws down for him an even greater and more enhanced measure of joy from Above” (Schneersohn, 1986, p. 34). Finally, the value of music and dance are recognised: “Listening to songs and . . . melodies, . . . walking in gardens . . . which delight the soul . . . and make the disturbance . . . disappear” (Maimonides, 1975 translation, p. 75). Rabbi Nachman of Bratzlav believed despair is shunned and solace and encouragement are provided by niggun [tune/melody] . . . dance, communion with the zaddik, and prayer. To be joyous is . . . a divine obligation . . . if you are sick or depressed . . . you dance . . . through dancing and body motions, joy is aroused (cited in Wiztum, Greenberg, & Buchbinder, 1990, pp. 124-125). In summary, rabbinic sources recommend a full range of cognitive, emotional and behavioural strategies for combating depression. The strategies all have an intrinsically spiritual flavour. Prayer and religious study, enhancing joyful mood, religious fellowship and guidance, practising kindness and the divine commandments are among the strategies to be used. Professional help-seeking: Here there are mixed views. The normative current rabbinic view favours professional help-seeking: (e.g., Greenberg & Wiztum, 2001; Leavey, Loewenthal, & King, 2007; Littlewood & Lipsedge, 1997; Loewenthal, 2006). Most contemporary Rabbis are willing to refer to and liaise with psychiatrists and psychotherapists, preferably religiously trustworthy and understanding of orthodox Jewish values and beliefs. The Lubavitcher Rebbe (Schneersohn, 2002, p. 151) warned that one must “ascertain whether the benefit he may receive . . . outweighs the long-time harm that may result” from some therapists’ approach, “deriding G-d, spirituality, honoring one’s parents and the like.” However the Lubavitcher Rebbe viewed positively Frankel’s (e.g., 1986) logotherapy approach that “faith . . . its connection to good deeds and finding meaning in life enhance man’s inner peace and tranquility” and expressed surprise “that his [Frankel’s] school of thought has not been sufficiently publicized and accepted” (Schneersohn, 2002, p. 150). It is generally known that depressed states can lead to self-destruction, and the Judaic imperative to preserve life is of the highest priority. Thus the statement: “Your blood of your lives will I require” (Genesis 9.5) is interpreted (Bleich, 1981, pp. 158-159) to consider that “the act of suicide is a cardinal transgression.” Therefore, a patient “in mortal danger” including the risk of suicide, must (if necessary) receive treatment “when tested and proven reliable . . . despite his protestations and . . . against his will” (Weiner, 1995, pp. 12-13). However, anti-psychotherapy views have been vigorously advocated. For example in 1993 the London Jewish Tribune reported that Rabbi Moshe Deutsch, Head of the Katamon religious court in London, expressing major concern about consulting “psychologists and others who are Apikorsim [a derogatory term . . . a heretic].”

Deutsch asserted that accepting psychiatrists’ advice was condemned by the greatest rabbis of Israel, America and Canada “because they are unprincipled and give advice that is against the Torah and transgresses Jewish Law.” Vigorous debate continued in the “Tribune” during 1993-1994; some Orthodox therapists advertised telephone counselling, Rabbis condemned them - whilst psychologists stressed the risks of depriving patients of therapy; they recommended publishing success rates for rabbinical management of psychiatric conditions. Greenberg and Witztum (2001, pp. 218-222) discussed reasons behind this negative rabbinical attitude to psychotherapy, including resistance to change, potential challenge of ultimate rabbinical authority, and the perception of psychotherapy as a “godless product of godless people.” Community-based factors can affect help-seeking. Individuals may use community-based support, including formal religiously sensitive psychological support and therapy (Loewenthal & Brooke-Rogers, 2004). But individuals may avoid any form of help-seeking for fear of becoming stigmatised as mentally ill (e.g., Cinnirella & Loewenthal, 1999; Greenberg & Wiztum, 2001). Rabbinic discussions of stigma were not identified. Among these themes, probably the most noteworthy are the rabbinic emphasis on the moral and spiritual aspects of depression, the possible role of personal failings in leading to depression, and the overcoming of depression by personal spiritual exertion. Also noteworthy is rabbinic emphasis on the religious suitability of any therapist from whom help is sought.

Community interviews

The aim of these interviews was to obtain current views on the causes of and treatments for depression from a range of individuals in the haredi (strictly orthodox) London Jewish community. Interviewees: Purposive/opportunistic sampling was used in selecting 10 interviewees from the London strictly orthodox community with a range of ages and views. There were five men and five women, age range 24-78; five hasidim (Chernobyl, Ger, Lubavitch, Satmar, and Vizhnitz) and five other haredim. There were three participants with some professional involvement in mental health care, three rabbis and the remaining four participants were community members. Interviewees were selected to give a range of knowledge of Jewish sources and of information about mental illness. It was anticipated that the sample size would enable sufficient saturation for thematic analysis. There were no a priori grounds for expecting gender differences; it was expected that the sample size was adequate for salient gender differences, if any, to be apparent. The semi-structured interview schedule asked for views on the causes, nature and management of depression, attitudes in the community, and whether treatment should ever be compulsorily enforced. The questions were chosen using guidance from the books cited, and from two clinical psychologists with experience in treating members of the haredi community, with the aim of encouraging interviewees to talk freely about the topics and develop their thinking during the interview. Interviewing was based on a qualitative, interpretive phenomenological analysis approach, (Rubin & Rubin, 1995, pp. 31-36, 145-167; Smith & Osborn, 2003, pp. 51-74) with elements of grounded theory (Charmaz, 2003, pp. 81-110). Questioning was modified as the interviews proceeded, to improve the relevance of responses.

Ethical issues: The Research Ethics Committee (REC) at University College London confirmed that the study met criteria for exemption from REC consideration. It was decided that, should a participant become distressed by discussing any issues, their general practitioner or Chizuk, the community’s supportive agency for people with mental health problems, would be consulted; this proved unnecessary. Analysis: Interviews were recorded, transcribed and analysed, guided by the approaches recommended by Smith and Osborn (2003, pp. 64-79) and Rubin (1995, pp. 226-256), identifying key themes from the first transcript, linking similar themes and adding relevant observations, quotations and new themes from all interviews. Notes were prepared on each theme, with relevant quotations. We will describe the emergent themes under same broad groupings as those in the rabbinic literature: causal factors, coping and professional help-seeking, before turning to a comparison of the rabbinic and community views. Causal factors: The salient intrinsic causal factors for depression mentioned by the community were biological and character predispositions: “chemical imbalance,” “the brain . . . not producing the right amount of chemicals,” “Something within themselves,” “Being less able than others to take stress.” Spiritual factors were occasionally mentioned: “Giving in to the evil inclination and not trusting G-d,” with a mention of using stress as an opportunity for growth: we are “meant to grow and learn and develop” from the “trials and challenges in life.” Extrinsic causes of depression, the “trials and challenges” included divorce, breakdown in relationships, family pressures, difficulties with children and harassment at work, as well as serious physical illness, with loneliness and not feeling understood making these harder to cope with. Financial problems, including redundancy, exacerbated by the recession, were specifically mentioned by many - linked to a “need for people to try to have more things they didn’t need in the old shtetl - where people were satisfied with everything . . . the need to have the same as others . . . money.” Management and treatment: A wide range of approaches was suggested, with a strong tendency towards attempting to identify and tackle underlying causes, including loneliness, relationship and financial difficulties, as well as seeking symptomatic relief. So, being helpful and friendly, reading “self-help books,” “distraction,” as well as “talking therapies” like counselling and psychotherapy, were thought by most to be potentially more helpful than drug treatment - which several thought should only be used as a last resort in severe depression. Prayer, reciting psalms and seeking help from a Rabbi were all mentioned - as was support from community organisations - including Chizuk and Smiley, described below. There was reluctance to consult psychiatrists, often because of the risk of stigmatisation - a disincentive to seeking treatment for mental health problems. Most participants accepted that patients suffering severe depression, lacking insight and not responding to treatment, might require treatment without their consent to safeguard their life and health. Jewish teachings about the vital importance of saving and preserving life were stressed and the importance of serving the Divine with joy - in prayer and action. More specifically, non-medical approaches were recommended first, since “any drug affects the brain.” “I certainly wouldn’t run to a psychiatrist in the first place and say ‘assess this boy . . . and if necessary give them medication’.” “Talking it through” with sufferers was recommended - “let’s try and look positive and see ways we can help you”; “having someone who understands can really help.” “Try to get them to help someone else - volunteering . . . give charity - that can help” and “distraction - get them interested in other things.” These could include “relaxation, swimming, other exercise - all known to alleviate depression” as well as art, drama and music which “people often use . . . to relieve their depressions . . . and of course King David - Saul.” Music is used therapeutically by the voluntary “Smiley” organisation who “take their guitars . . . go to the home or . . . hospital and play music . . . sing to him or her, you know, and snap her out of the depression . . . and help them.” “They just go and make people happy . . . smile therapy . . . affects endorphins - no drugs, no cost.” Self-help was thought valuable for many people, including reading from the “Jewish literature for people to seek solace when they are feeling low.” Authors recommended included Rabbi Dr Abraham Twersky, Rabbi Yitzhak Frand, Rabbi Selig Pliskin, Petach Krohn and Rabbi Horowitz. Rabbi Spitz’ self-help book, (2008) based on his own experience of depression and recovery, offered “practical guidance distilled” with constructive suggestions for sufferers, based on Jewish teachings. Rabbi Pliskin’s “Gateway to Happiness” (1983) also provided a practical self-help guide, packed with advice based on Jewish teachings, using techniques he had found useful in his counselling practice, stressing that “happiness is a skill that can be learned,” and drawing on a range of rabbinic sources presenting discussions of the religious obligation to be happy, the importance of appreciating what one has and realising one’s self-worth. These views were reflected by the interviewees. Jewish family magazines (including “Mishpacha,” “Binah” and “Jewish Press”) were also thought to contain useful guidance - “they will tackle subjects that never used to be talked about.” Also recommended, for those haredim prepared to use computers, were Jewish websites such as “ilovetorah” run by Reb Moshe of Tsfat, providing guidance on the importance of simchah (joy) in Judaism and ways of achieving it. Complementary/alternative medical treatments such as Shiatsu and healing were also thought useful by some: “the ability to be a healer . . . with eyes, with voice . . . with touch is mentioned in the Talmud . . . in the Gemara.” Religious approaches involved prayer, consulting a Rabbi, and turning to Jewish teachings. Praying was mentioned by almost all (nine) interviewees; “there is no doubt that, without prayer, nothing happens . . . without the help of God, nothing happens.” Specific prayers or - particularly - reciting psalms “help to relax me, to calm me” and “are there for anybody in a difficult situation.” Specific prayers were not the only way: “Pray to God - tell Him you are not managing - not coping - we strongly believe you can pray in any language and any form - you can say literally ‘God, help me’.” The Rabbi is often approached for advice and support. This is often the Rabbi of one’s congregation, but may be another Rabbi or Rebbetsen (Rabbi’s wife, or other woman communal figure) in the community known for their expertise and counselling skills. “Pour one’s heart out to him - he’s there to help you.” Others emphasised that some Rabbis were “particularly clued up on possible forms of treatment and can be very good sources of advice on where to go for help” and that “they would receive good understanding and appropriate advice . . . on balance most of it is pretty good.” Direct study of Jewish sources is also popular: “learning from texts like Chumash (Pentateuch) - and then the Gemara (Talmud) . . . they say that, although it is very difficult, it can give a person pleasure - I’ve heard it can actually take a person out of depression - and learning a Jewish teaching can give a person pleasure - in my opinion.” What about professional help? Counselling and psychotherapy (these terms were sometimes used interchangeably) “including analytical and psychodynamic to cognitive behavioural therapy (CBT) which is all the vogue at the moment” were thought, when used appropriately in selected cases, to “help with understanding [because a] therapist gives you space to reflect . . . access what is causing depression.” Other professional interviewees also recommended CBT. Logotherapy (Viktor Frankl Institut, 2012), which helped “develop a sense of meaning and purpose . . . has to come from inside”, was thought valuable, since “depression derives from an unfulfilled desire for meaning in life.” Some sufferers were thought unready for therapy - if they saw no point in it; they needed “to be left to themselves until they wanted treatment.” However interviewees recognised sufferers might need encouragement or pushing to accept help; one quoted: “Open for me the eye of a needle and I shall open for you a hallway” (Shir Hashirim Rabbah, 24). Several interviewees stressed: “when it comes to counselling . . . it is absolutely essential that patients see someone that is sensitive to their cultural, ethnic and religious background, needs and understanding - and preferably if they actually come from that background.” Medication was recognised by all as necessary for severe depression; it could, especially “if enzymes lacking . . . close the trap door to the worst feelings and . . . be very helpful.” A more cautious view was: “(medication) can be useful but not a complete answer; [doctors were] too quick to give antidepressants without exploring causes.” A balanced view: “the whole spectrum - with two extremes - talking therapies - to medication/other therapeutic interventions - if used appropriately, both help - sometimes combined.” However, if someone in his family were affected, he would approach “a sympathetic, understanding doctor who understands the cultural background.” Electroconvulsive therapy was thought acceptable by some if medication proved unsuccessful, although others felt uncomfortable about it; “there is a place for it, but within the Jewish community people don’t like drastic forms of intervention - one, because of the stigma.” Treatment without consent was considered necessary by the three rabbinically qualified interviewees, in severe, unresponsive depression “if needed for protection.” “If they are a danger to themselves, it is acceptable to treat them forcibly and ‘section’ them - you cannot allow someone with depression to take their own life.” “In Judaism, the paramount thing is life . . . if it’s the only way to save someone’s life, handcuff them - sectioning is a form of handcuffs.” The rabbis recognised the risk of doing psychological harm but “if they’re dead, they don’t get any deader - if they are psychologically messed up, they might get better - you choose!” One lay member recognised: “it’s against the Torah to commit suicide - I’d be desperate - you’d try anything you could . . . ask family - especially mother, husband - and friends; bring in a professional and ask the person to speak to them . . . I’ve got to know I have done my best. I’d ask the Rabbi, and if he thinks it necessary, I’d allow them to be treated against their will’. However some lay participants felt very uneasy about this prospect.” It was suggested that the principle of pikuach nefesh (saving human life) by “transgressing” on Sabbath - if considered necessary, in selected cases, and with rabbinical guidance, could be extended to measures to improve the quality of life to a bearable level in depressed patients. The community itself was seen to influence depressive illness in several ways, particularly via social support, culture brokers, and (a negative influence) stigma. Social support included informal support via friends, family and neighbours, as well as several community-based organisations focused on supporting those with mental health problems. Most interviewees referred to the family’s and the community’s wish to help: “a huge amount of goodwill . . . of quiet help . . . of real care - of Ahavas Israel”; visiting and cheering people - family, friends and others. Whilst “some people . . . [are]scared by psychiatric illness - others very sympathetic and will try to help [although] they don’t always have the ability.” Also stressed was the potential help, for depressed patients in North London’s haredi community, from several organisations, particularly Chizuk - which had done much to remove stigma as well as reducing isolation by offering drop-in sessions, drama and art therapy, and providing family and carer support and advocacy for depressed patients. Other community organisations mentioned included Bikur Cholim, run by the Satmar community, “Talking Matters,” which offered talking and complementary therapies and counselling training - and Smiley, which use music and singing to alleviate suffering. “Culture brokers” are individuals from the community who have developed a range of contacts, in this case in mental health service provision. They may have professional qualifications themselves. Such individuals have an insider understanding of the needs and sensitivities of orthodox Jews, and are able to advise and, as needed, organise and arrange professional help with these needs and sensitivities in mind. Culture brokers were recommended “to help ensure all get best treatment.” One professional found them “incredibly helpful and useful; people revere them and respect their views - if I don’t take that into account [I would be] shooting myself in the foot.” Stigma was raised spontaneously by nine interviewees as a problem - a major disincentive to people seeking and receiving appropriate help and treatment: “Quite big . . . more in the uninformed . . . who are not knowledgeable medically - they may say no to anything (treatment) like that - to the extent that it is actually detrimental to the . . . depressed person’s health.” People were said to be reluctant to accept treatment, especially if they were single - “because the whole marriage concept - how it works - it’s much harder to get someone the help they need.” This reasoning behind stigma was repeatedly described explicitly: it would damage prospects of a shidduch (marriage introduction) - “even if the person completely recovered or it was (their) mother . . . affected.” “If we admit one of our children has a mental problem, it will affect their shidduch and their siblings” shidduch - so we lock them away’, “trying to ‘keep it quiet”’; they would “hide people away . . . Down’s children kept at home.” If a “child developed mental problems . . . they just used to lock up these children in the cupboard and not let them out.” There were said to have been recent improvements; “a much healthier attitude today than there used to be,” and it was recognised that “certain individuals and groups have . . . done a tremendous amount of work to break down the barriers and myths and bring the topic of depression and psychiatric illness into the open.” Nevertheless, although mental illness is discussed more openly, it may still be heavily stigmatised.

Rabbinic and community views compared

The community views represented here can be compared and contrasted with the rabbinic views surveyed in the earlier part of this report. We can compare emerging themes from rabbinic and community sources; quantitative comparisons are not possible. With regard to the causes of depression, rabbinic sources focussed on external events (stressors) and personal failings (sin). Greenberg and Shefler (2008) raise the question whether rabbis, in responding to questions about mental health difficulties, are functioning to protect the law, or to alleviate suffering. Greenberg and Shefler conclude that while the rabbis’ responses are based on detailed knowledge of Jewish law, their approach is based on extensive clinical experience, and their primary aim is to help the patient. Rabbinic discussions of sin could be seen as aimed at promoting a healthy self-awareness and self-esteem, rather than as guilt-enhancing. Additionally it may be worth noting that some rabbinic views pre-date contemporary advances in medication and psychotherapy, so suggestions about self-examination may have been one of the few possibilities then available.

In the community, stress was also seen as a factor, with a number of specific aspects being identified, particularly isolation. Unlike the rabbinic sources, community informants (who included three rabbis) gave attention to intrinsic causal factors, particularly biological vulnerability, but most did not mention personal failings (sin) - although one recognised that guilt feelings from perceived sin could be either a result (symptom) or a cause of depression. We thought this contrast quite striking. We cannot be confident about the reasons for this discrepancy, but one possibility is that the rabbinic sources are exhorting people to examine their ways. Such exhortation would be inappropriate in the context of a research interview. Rabbinic and community views on help-seeking were generally in accordance. Both agreed on the helpfulness of rabbinic and other religious guidance, social support, religious coping, and where appropriate, medication and professional psychotherapy. Both agreed that coercive treatment to save life was important. The main differences in emphasis were a minority rabbinic view that psychotherapy should be avoided because of the risks of undermining faith. However the normative rabbinic view resembled that of the community - carefully chosen, religiously approved psychotherapy could be a helpful option. Secondly, in the community, there were significant reservations about medication, often seen as risky and unhelpful; a last resort. The community endorsed a wide range of complementary treatment options (music, self-help books, healing, shiatsu) not attended to in the rabbinic literature. The community informants also mentioned an important gateway to professional help-seeking, the culture broker, not mentioned in the rabbinic literature. A striking feature of the community views was the attention given to stigma, a factor not considered in the rabbinic literature. A number of possible factors might help to account for the community emphasis on stigma. Mental illness in the family often affects the marriageability of other family members. There may be fear of hereditability, and also concern about the family-wide responsibility for supporting someone with psychiatric difficulties. Additionally, blame may be attached to mental illness, and this might be linked to knowledge of the rabbinic literature on self-help: we might speculate that stigma is attached to the person who has been unable to help themselves sufficiently. Some of these features of the community views may be the result of exposure to nonrabbinic views. Although extensive secular education, television and internet use are discouraged in this community, a good basic secular education is normally offered and many people will read selected books and newspapers, offering among other things information on medical and psychiatric treatment. Some had direct experience of mental illness - among family and friends, or in three cases, from professional involvement, and this may have impacted on their views, for example making them more pragmatic in their attitude to treatment without consent. There was no indication that those involved in mental healthcare had biased understanding or views, for example in being more in favour of (or against) medication. The absence of concern with stigma in the rabbinic literature may simply be that our searches concerned only rabbinic views on causes of and coping with depression. Concern with the opinions of others was not apparent in this context. There is an extensive rabbinic literature on avoiding gossip and speaking about negative characteristics of others (see e.g., Loewenthal, Glinert, & Goldblatt, 2003), indicating a keen awareness of the importance of reputation and respect in the community, and the ease with which damage can be done, but coping with depression was not a context for such rabbinic concerns. The similarities in rabbinic and community views are associated with the community’s ongoing exposure to the general principles expounded in the rabbinic literature, via synagogue sermons, regular religious study sessions, everyday conversation and the orthodox Jewish press. All are saturated with the general principles of the importance of helping others, showing kindness, and the sanctity of life. These have the status of culturally carried values. Thus, we see some broad agreement between the rabbinic and community sources in their views on the causes and treatment for depression. However there are differences, and the most salient of these are the issue of sin, which is salient in the rabbinic literature, and of stigma, salient in the community views.