“PLEASE DON’T TELL MY KALLAH”

By: Dr. David H. Rosmarin

Courtesy of Mishpacha magazine

Though this is an actual case history, please realize that every situation is different, and matters should be discussed with a knowledgeable Rav and competant mental health professional

Mr. Dovid Simmons is a twenty-five-year-old man who called our office in a panic. As the oldest brother of four unmarried sisters between the ages of seventeen and twenty-three, two currently in Shidduchim, Dovid was ecstatic to inform us that he recently became engaged to a lovely young woman. However, he was petrified by one important detail: during their brief courtship, Dovid had neglected to mention to his kallah that he suffered from Obsessive Compulsive Disorder (OCD). Dovid confided in us that his parents expressly forbade him from disclosing any information about his symptoms to his kallah or her family out of concern that the revelation might have repercussions on Dovid’s and on his sisters’ prospects for marriage.

“Dovid was now in a terrible bind, and stated that he wanted to overcome his OCD prior to his wedding (in just twelve weeks). To make matters worse, Dovid wanted to accomplish these goals without any pharmacotherapy and without his kallah knowing anything about his treatment.

Dovid’s obsessions included worrying whether he had said brachos over food and mitzvos properly or at all, whether he had spoken lashon hara, and whether he had created an ayin hara when speaking about the future. Dovid’s compulsions included overly scrutinizing his words, confessing to his rebbeim, and avoiding certain topics of conversation altogether.

Further, at times Krias Shema would take Dovid twenty minutes – not because he wanted to daven to Hashem, but because if he was interrupted in any way he felt compelled to go back to the start. Dovid would also obsess for hours on end about his tefillin and compulsively check them to make sure they were on straight.

As is characteristic of OCD, Dovid recognized that his symptoms were on the low to moderate end of the spectrum. In fact, to an outsider, Dovid probably just appeared very frum, and perhaps it was for this reason that his symptoms went undetected by those involved in his shidduch. Dovid was nevertheless suffering and impaired in several areas of his life, and he needed help

Course of Treatment

Dovid’s intake assessment was completed by Dr. Debra Alper, a supervising psychologist in my Manhattan office. Recognizing that Dovid’s case was complex, Dr. Alper informed Dovid that she would need to discuss his situation with the Center for Anxiety clinical staff in order to determine the best way to proceed. Immediately after the intake, Dr. Alper sent around a request for a consultation and discussion about this challenging case.

During our meeting, a number of important questions were raised: Dovid should have told his kallah about his OCD. Should we encourage him to inform her now, after their engagement? Might this lead to a broken engagement, and possibly years of loneliness and increased distress for Dovid and perhaps his sisters as well? If we did encourage Dovid to inform his kallah and he refused, would we then be obligated by Halachah to inform her or her family? If there was indeed a duty to inform the family, did it apply when we would be breaching Dovid’s confidentiality, thus putting our practice at risk(i.e., possibly making us unable to service the community in the future)? If we did not inform the family, would we be responsible for any damage caused to Dovid’s kallah if their shidduch - or worse, their marriage and family life! – did not work out due to Dovid’s OCD?

Furthermore, Dovid’s plan to be cured was far from a sure bet; although his symptoms were not severe and he was highly motivated for treatment, Dovid was attempting to deal with his OCD in a matter of twelve weeks. We knew we were obligated to tell Dovid our prognosis and about the potential risks of treatment, but should we accept his case?

Later that day, I called up the Center for Anxiety’s Mara d’Asra Harav Dovid Cohen, shlita, to discuss our questions. He stated that Dovid and his parents were committing a serious aveirah by not notifying his kallah about his OCD. However, he paskened that while we should encourage Dovid to tell his kallah about his symptoms , in this specific case, we ourselves had no obligation to inform her or her family if he refused to do so, because of the possibility of a tremendous loss. He further ruled that if we thought we could help Dovid, we should try to do so, and ended the call with a brachah that we be able to help all of our patients.

Based on that psak, we reconvened and decided to treat Dovid. Our collective impression was that Dovid’s best likelihood of medication would be via an intensive treatment program. Intensive treatments for OCD vary in length and duration depending on the nature and severity of a patient’s symptoms, as well as practical constraints, but based on Dovid’s clinical profile and strict timeline of ten to twelve weeks, we estimated that Dovid could make significant treatment gains with two to four weekly sessions of two to four hours each. As a team, we determined that Dr. Alper would be an appropriate therapist for Dovid, based on her expertise in treating OCD in young adults. Our office manager, Ms. Aliza Sklar, called Dovid and he agreed to proceed with our recommendations.

Dovid’s treatment involved Exposure & Response prevention (ERP), a cognitive-behavioral treatment for OCD that is extremely well researched and empirically supported. ERP involves the patient facing his /her fears head-on while limiting, and ultimately eliminating, any compulsive and avoidance behavior. From a neurobiological perspective, ERP can modify the dysfunctional neural circuitry associated with OCD and other anxiety disorders. Experientially, while Dovid knew intellectually that his fears were unfounded even prior to starting treatment, engaging in ERP helped draw that message down deep into the recesses of his heart (and brain).

In this case, an important caveat was the most of Dovid’s OCD had some resemblance to Torah observances and care had to be exercised to make sure that Dovid could face his fears without contravening Halachah, chas v’shalom. Dr. Alper needed to confer with Dovid’s daas Torah authority in designing and implementing Dovid’s treatment regimen, as his specific exercises included saying brachos without repetition in a way that felt (but truly wasn’t) improper, engaging in anxiety-provoking conversations, limiting Shemoneh Esrei to a maximum of seven minutes, stopping all tefillin checking, and similar activities.

Dovid was highly motivated and although treatment was extremely difficult – Dr. Alper had to push him past all of his OCD symptoms in just a few weeks! – Dovid was a perfect patient as far as compliance goes. He showed up early to each session, completed all of his homework diligently, and went above and beyond his treatment goals at several points throughout his course of treatment.

Outcome of Treatment

Over the next twelve weeks, Dovid visited our office approximately twenty-five times. At his last session, four days before his wedding, Dovid was virtually symptom–free. He was able to recite brachos without repeating, hold conversations about almost any topic without significant fear, and daven appropriately. Furthermore, he had cut out all of his checking compulsions and was able to wear his tefillin without fanfare or distress, all without any medication.

Reflecting on his successes, Dovid said: “You have changed my life. I’m not embarrassed that I’ve struggled with OCD and at this point I intend to tell my kallah about it one day. I just wish my family and our community wasn’t so terrified of mental health issues. In my case, I truly had nothing to be afraid of – except for fear itself.”