“Substance Abuse in the Jewish Population”

By Joseph A. Hirsch, PhD, PsyD and Steven Mandel, MD

In the most recent report by the World Health Organization over 3 million deaths occur annually that are attributable to alcohol consumption and psychoactive drug use. 1 The overwhelming majority of these deaths are in men. How many Jews in the United States and worldwide are affected is not known. Both the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Disease Control (CDC) report licit and illicit substance use/disuse (including alcohol and tobacco products) by race and ethnicity, neither specifically identifies prevalence in the American Jewish population. 2,3

The best estimate of North American alcohol and substance abuse in Jews comes from a recent Canadian pilot study. Approximately 15% of the mostly Jewish respondents indicated drug dependence. However, the sample from Winnipeg was very small in size, possibly not be representative of the socially and culturally different United States and was markedly skewed in terms of age and sex.

Background

The problems concerning identification and thus treatment of a substance use disorder in the Jewish population are multifactorial. One fallacy is that Jews cannot become alcoholics or have addictions. 4 Also contributory are denial amongst substance abusers and their loved ones and the fear of stigmatization. 4. Of course, some of these beliefs and fears are common to the larger population but are especially amplified in Ultraorthodox Jewish (Haredim) young men. 5,6 Particularly vexing is the perceived lack of support and attention from various social systems and ostracization from family, educational institutions and community.

We believe that Jewish religious teaching is confusing and may unintentionally contribute to alcohol misuse in vulnerable individuals. For example, the Bible is critical and even condemnatory about drunkenness (e.g., Noah), with a strict proscription against excessive alcohol consumption. 7 Nevertheless, moderate ingestion and even, at times, excessive consumption (e.g., during Purim, joyous banquets) is encouraged. 7,8 Alcohol, after all, is typically used during Passover, weddings and some other Jewish religious rituals. Here lies the rub, to paraphrase the great bard, William Shakespeare. On the one hand use of alcohol in religious services may be tempting for vulnerable individuals. However, frequency of attendance to religious services (Jewish or other) apparently inoculates some adults against alcohol, tobacco, or cannabis use disorders. ,9,10 In fact, it is suggested that religious leaders and clinicians consider utilizing religious social support structures in the prevention and treatment of substance use disorders. 9,10

Epidemiology and genetics

As previously mentioned, there is a fallacy that Jews cannot become addicts. Although much research states that alcoholism is lower in Jews than non-Jews, it is certainly not zero. 11 Unfortunately much of the reported epidemiological surveys is decades old. One study, in particular, involves re-analysis of data from the Epidemiologic Catchment Area study that was first initiated more than 40 years ago. 11,12 Initially it was believed that religious orthodoxy conferred some were type of immunity to alcoholism but even as far back as the 1970’s, with increasing assimilation of Jews, the low rates of alcoholism were maintained. 13 The researchers believe that core tenets and practices (true or not) that are taught by parents and others to their children may inoculate even assimilated Jews from alcoholism: the belief that alcohol abuse is associated mostly with non-Jews, mirroring moderate drinking norms and behaviors during religious and non-religious rituals, preferentially socializing with moderate imbibers rather than with those who drink to excess, and adopting techniques to resist social pressure to overindulge in alcohol.

However, there has been no definitive research on the epidemiology of Jewish alcoholism in decades. In fact, neither specific religious or cultural factors have been convincingly identified and even genetic studies do not fully explain lower prevalence rates 14 The higher prevalence of an allele of one of the nineteen genes of the enzyme aldehyde dehydrogenase (ALDH2) may contribute to the lower rate of alcoholism in Ashkenazi Jews (as opposed to Jews of other heritage, like Sephardic or Mizrahi). 14,15. First discovered in East Asians, this allele (ALDH2*2) is due to a mutation and causes characteristic facial flushing, headaches, nausea, dizziness, and cardiac palpitations after consumption of alcoholic beverages leading to alcohol avoidance. 16 As the largest substratum Jewish group (2/3 of all American Jews) this is significant. 17 However, these caveats beg explanation: (1) The study conducted was very small (2) Inactive ALDH2 is not always associated with a low risk of alcoholism and active ALDH2 is not always associated with high risk and (3) a plethora of genetic, other biological, behavioral and psychological factors interface in determining addiction. 5,14,18 Most significantly, when we consider addiction to a host of licit and illicit substances other than alcohol (e.g., nicotine, opioids, cannabis, psychostimulants), most of the discussion so far is not applicable from the epidemiology, to religious rituals (in the Jewish religion only alcohol is used), to genetics, and to neurobiology. In fact, Jewish education and Jewish law address, sometimes contradictory dicta about imbibement of alcohol, but say nothing of other psychoactive substances. 19

Differences in religious affiliation and attitudes

Religious affiliation may differ in terms of casual use of alcohol or other drugs for sacramental purposes. 20 For example, wine is commonly used in the Jewish Passover and the Catholic Eucharist and hallucinogens may be used in some Native American rites, but not in most other Christian denominations or other religions. However, addiction is generally not accepted.

Many religious faiths embrace religious or spirituality as a component to treatment. 20 Indeed, Alcoholics Anonymous (AA) actively embraces spirituality and encourages acceptance of a “higher power” without endorsing a specific religious practice. 21 Regardless of religious affiliation, those who identify as orthodox more strongly prefer spiritually-based interventions (e.g., psychotherapy) than those who do not. 20

Alcoholism as an “illness” is conceptually embedded in the precepts of AA. In more recent years a specific disease model for substance abuse has been also been advanced by the notable research neurobiologists, Alan Leshner, PhD, previous director of the National Institute on Drug Abuse (NIDA), and Nora Volkow, MD, NIDA’s current director. 5 This perspective, rather than moral failing, is more likely to be embraced by Jews, especially non-orthodox, than Christians. 20 This has important implications for treatment, especially pharmacotherapy.

Subgroup differences amongst Jews

There has been little research in the last several decades that clearly compares addiction in the Jewish community as a function of religious denomination. However, the stigma of alcoholism in the Jewish community exists across religious denomination (Orthodox, conservative, reformed, nonreligious/other). 22 By comparison the stigma of suffering from anxiety and depression is minimal.

Sex differences in attitudes concerning alcoholism do exist. 22 Female alcoholics are both less stigmatized than their male counterparts and are more likely to be sympathetic of those that seek treatment.

Treatment Considerations

As with all pathophysiological and psychological condition, the problem of Jewish substance
abuse needs to be identified. If patients are in denial they are highly unlikely to seek treatment. This is where family and friends may serve as a useful bridge.

Psychotherapy, a main treatment option, is sorely underutilized by ultra-Orthodox Jews. 23
Orthodox Jewish resistance to psychotherapy is contradistinct to non-Orthodox Jews, who are far more likely than others to become patients. 24 In some ways this is not surprising since many deeply religious people of other faiths are also reluctant to engage in psychotherapy. 23 They are afraid that therapists will pathologize their beliefs, rituals, and traditions. For Orthodox Jews, engagement in psychotherapy presents specific challenges. Orthodox Jews may believe that life’s vicissitudes are religious tests from God that devout Jews should be able to pass without outside help. Thus, seeking therapy may be understood as a personal weakness or that the addict is insufficiently devout. 23 On the other hand the creators, practitioners, and intellectual giants of psychotherapy have disproportionately been Jews. 24 These include the seminal originator of psychoanalysis, Sigmund Freud, behaviorists Joseph Wolpe and Arnold Lazarus, rational emotive behavioral therapist Albert Ellis, cognitive behavioral therapist Aaron Beck, and a host of other less traditional therapists (e.g., Irvin Yalom, Eric Berne, Fritz Perls). 24

Lost in the discussion of resistance to treatment by some in the Jewish community is the perhaps counterintuitive reality that pastoral counselors, including rabbis, have long practiced psychotherapy. 25 Rabbis, of course, may also earn degrees in medicine, psychology, social work, or nursing. Presently, Yeshiva University in New York City offers a certificate in pastoral counseling through its joint program of the university’s Rabbi Isaac Elchanan Theological Seminary and its Ferkauf Graduate School of Psychology. 26. Training in substance abuse treatment is one of the program’s course offerings.

Spirituality and religion

Mainstays in treatment of substance use disorders are the now very traditional, non- denominational spiritually driven 12-step programs like Alcoholic Anonymous, Narcotics
Anonymous and the like. 27 Also available is a 12-step program specifically targeting Jewish
substance abusers — Jewish Alcoholics, Chemically Dependent Persons and Significant Others (JACS). 28,29. It is offered by the well-established and respected 150-year-old Jewish Board. The impetus for the founding of JACS was the recognition that many traditional AA groups, though non-denominational,” seem to have a subtle Christian orientation that makes many Jewish people uncomfortable.” 30 Many participants find these meeting helpful in their learning to accept their own addictions and thus not falling prey to the canard — only gentiles are shickers. 30,31.

Religion is the belief in and worship of one or more gods whereas spirituality is the “capacity of persons to transcend themselves through knowledge and love … to reach beyond themselves in relationship to others and thus become more than self-enclosed material monads.” 32 Whether or not to introduce religious versus non-religious spiritual-related treatment is strongly dependent on the individual. It is noteworthy that American Jews are less likely than non-Jews to attend religious services or to believe that religion is very important to them. 33 Only one quarter of American Jews even accept a biblical depiction of God but many non-religious individuals still identify as being spiritual. 32,33 Regardless, Jewish alcoholics may opt to pursue spiritual (in the larger sense), religious, or non-religious-based treatments. A recent small study yielded some interesting results that defied expectations. 34 Adult Orthodox Jewish patients were just as likely to benefit from psychotherapeutic services offered by non-religious therapists regardless of religious affiliation as from Jewish practitioners. So, preference in therapist’s religiosity is an important consideration in attracting patients but may have little bearing on success of treatment.

Final Thoughts

Whether Jews are less susceptible to alcohol or other addictions — which is questionable, they are still susceptible. It is important that individuals recognize and accept that they suffer from addictions and seek effective treatment. If they are too much in denial to accept their own addictions it is incumbent that family members, colleagues or friends perform the mitzvah of addressing the problem with their loved ones so that effective treatment can be given. Remember the Talmud instructs us: “Whoever saves one life saves the entire world.” 35

Joseph A. Hirsch, PhD, PsyD

Dr. Hirsch is a licensed psychologist (active) and pharmacist (inactive). He is a clinical neuropsychologist, psychotherapist, hypnotherapist and virtual reality therapist. He is an adjunct professor of psychology at Pace University in New York City, where he teaches psychopharmacology. Dr. Hirsch earned doctorates in pharmacology and psychology.

Steven Mandel, MD

Dr. Mandel is a board-certified neurologist. He is a clinical professor of neurology, Zucker
School of Medicine, Hofstra Northwell Health System and adjunct professor of medicine, NY
Medical College.

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