Depression, PTSD, and suicidal ideation among ex-ultra-Orthodox individuals in Israel

ABSTRACT

Introduction: Disaffiliating from an ultra-Orthodox society is complex and challenging. The process includes dealing with culture shock, traumatic experiences, education gaps, and disconnection from familiar surroundings. Thus, ex-ultra-Orthodox individuals (ex-ULTOIs) may face loneliness, lack of belongingness, and loss of meaning, which may relate to high psychological distress such as depression and suicide ideation. In the present study, we sought to shed light on the distress of ex-ULTOIs in Israel and to understand the disaffiliation-related characteristics that may relate to their distress levels.

Method: The sample comprised 755 participants, aged 19–54, who left their ultra-Orthodox Jewish lifestyle and communities. Participants completed self-report questionnaires tapping depression, anxiety, posttraumatic stress disorder (PTSD) symptoms, suicide ideation and behaviour, as well as demographics and disaffiliation-related characteristics.

Results: Nearly half of the sample (N = 332, 45.9%) reported symptom intensity meeting the current criteria for major depressive disorder. Moreover, 46.7% reported symptoms meeting PTSD criteria, and 34.5% reported having suicidal ideations in the past year. Hierarchical regression analyses revealed that the intensity of past negative life events, the nature of motives for disaffiliation, and the longer duration of the disaffiliation process contributed to the severity of distress.

Conclusions: The study's findings reveal that ex-ULTOIs suffer from high mental pain levels, particularly depression, PTSD, and suicidal risk. Importantly, experiencing disaffiliation as traumatic and longer durations of the process may facilitate greater mental pain and distress symptoms. These findings emphasize that ex-ULTOIs must be continually assessed, especially when their disaffiliation processes are experienced as traumatic.

HIGHLIGHTS

• Ex-ultra-Orthodox Jews reported relatively high levels of depression, posttraumatic symptoms, and suicidal risk.

• Half of the sample met the criteria for major depressive disorder and PTSD, and more than a third reported suicide ideation in the past year.

• The intensity of negative life events in the past and a shorter duration of the disaffiliation process contributed to higher severity of mental pain among ex-ultra-Orthodox individuals.

Introducción: Desafiliarse de una sociedad ultra-ortodoxa es complejo y desafiante. El proceso incluye lidiar con el choque cultural, experiencias traumáticas, brechas educativas y desconexión del entorno familiar. Por lo tanto, las personas ex-ultra-Ortodoxas (ex-ULTOIs) pueden verse enfrentadas a soledad, falta de pertenencia y pérdida de significado, lo cual puede relacionarse con un malestar psicológico elevado como depresión e ideación suicida. En el presente estudio, buscamos esclarecer sobre el malestar de los ex-ULTOIs en Israel y comprender las características relacionadas con la desafiliación que pueden relacionarse con sus niveles de angustia.

Método: La muestra estuvo compuesta por 755 participantes, edades entre los 19 y 54 años, que abandonaron el estilo de vida y comunidades Judías ultra-Ortodoxas. Los participantes completaron cuestionarios de auto-reporte sobre síntomas de depresión, ansiedad, trastorno de estrés postraumático (TEPT), ideación y conducta suicida, así como también características demográficas y relacionadas con la desafiliación.

Resultados: Cerca de la mitad de la muestra (N= 332, 45.9%) reportó síntomas cuya intensidad cumplía con los criterios actuales de trastorno depresivo mayor. Además, 46,7% reportó síntomas que cumplía con los criterios de TEPT y 34,5% informó haber tenido ideación suicida en el último año. Los análisis de regresión jerárquica mostraron que la intensidad de los eventos pasados negativos, la naturaleza de los motivos de la desafiliación y la mayor duración del proceso de desafiliación contribuyeron a la gravedad del malestar.

Conclusiones: Los hallazgos del estudio revelan que ex-ULTOIs padecen de altos niveles de sufrimiento mental, particularmente depresión, TEPT y riesgo suicida. Es importante destacar que experimentar la desafiliación como un proceso traumático y de mayor duración puede facilitar mayor sufrimiento mental y síntomas de angustia. Estos hallazgos enfatizan que exULTOIs deben ser evaluados continuamente, especialmente cuando los procesos de desafiliación se viven como traumáticos.

简介：脱离一个极端正统的社会是复杂而具有挑战性的。 该过程包括应对文化冲击、创伤经历、教育差距以及与熟悉环境的断开。 因此，前极端正统派人士 (ex-ULTOIs) 可能面临孤独、缺乏归属感和失去意义，这可能与抑郁和自杀意念等高度心理困扰有关。 在本研究中，我们试图阐明以色列前 ULTOI 的痛苦，并了解可能与其痛苦程度相关的离群相关特征。

方法：样本包括 755 名19 至 54 岁之间的参与者，他们离开了极端正统的犹太生活方式和社区。 参与者完成了自我报告问卷调查，内容涉及抑郁、焦虑、创伤后应激障碍 (PTSD) 症状、自杀意念和行为，以及人口统计学和离群相关特征。

结果：将近一半的样本 (N = 332, 45.9%) 报告症状强度符合当下重性抑郁障碍标准。 此外，46.7% 的人报告症状符合 PTSD 标准，34.5% 的人报告在过去一年有自杀意念。 分层回归分析表明，过去消极生活事件的强度、脱离动机的性质以及脱离过程的较长持续时间都导致了痛苦的严重程度。

结论：该研究结果表明，前 ULTOI 患有严重的精神痛苦，尤其是抑郁、PTSD和自杀风险。 重要的是，经历作为创伤的离群和较长的过程持续时间可能会导致更大的精神痛苦和心理困扰症状。 这些发现强调必须持续评估前 ULTOI，尤其是当他们的脱离过程经历了创伤时。

KEYWORDS:

• Disaffiliation
• depression
• PTSD
• suicide ideation
• ultra-Orthodox

PALABRAS CLAVE:

• Desafiliación
• depresión
• TEPT
• ideación suicida
• ultra-Ortodoxo

关键词:

• 脱离
• 抑郁
• PTSD
• 自杀意念
• 极端正统

Introduction

It is well-established that immigrants and ethnic minority groups present significantly higher levels of mental pain––i.e. depression, anxiety, posttraumatic stress disorder (PTSD), and even suicide––than non-immigrant populations (Forte et al., 2018; Hass, 2018). Immigration challenges can comprise a stressful condition that may cause psychological distress and suicidal behaviour (Bursztein Lipsicas et al., 2012), exacerbated by risk factors like loss of social status, worries for the family left behind, loneliness, and detachment (Amit, 2010; Bursztein Lipsicas et al., 2012). A group comprising a unique type of cultural immigrants is former ultra-Orthodox Jewish individuals (ex-ultra-Orthodox individuals; ex-ULTOIs), who leave the ultra-Orthodox Jewish lifestyle and community (Davidman & Greil, 2007). Those leaving their closely-knit religious community, such as the ultra-Orthodox community, experience the transition as an extreme form of immigration (Engelman et al., 2020). Since the only culture they know is that of the hierarchical conservative community, ex-ULTOIs need to adapt to a new, completely foreign way of life (Myers, 2017). Even if the transition involves only a short-distance move physically, the disaffiliation process can be experienced as a migration to a new culture, requiring learning new behaviours, new habits, and often a new language (Davidman, 2015).

Leaving an ultra-Orthodox community is complex, during which ex-ULTOIs face many challenges striving to establish a new sense of identity and settling into a new community (Berger, 2015). Many are left without support systems, losing their family and social ties, and some are even left homeless (Davidman, 2015). Ex-ULTOIs also face gaps in education and the lack of basic tools for occupational and social integration in modern society (Horowitz, 2018). Thus, the challenges faced by ex-ULTOIs, similar to those faced by immigrants, in addition to the unique challenges of this type of immigration, may place them at increased risk of experiencing psychological distress and suicidal risk.

There is a dearth of data on the impact of disaffiliation on psychological distress. However, some studies have noted that disaffiliation from religious groups carries psycho-social ramifications (Fenelon & Danielsen, 2016; Myers, 2017), especially regarding rigid, closed, and extreme religious groups (Berger, 2015; Davidman & Greil, 2007; Fenelon & Danielsen, 2016). These ramifications include loss of supportive relationships, difficulty establishing a solid sense of identity, and psychological distress (Fenelon & Danielsen, 2016; Myers, 2017). In addition, ex-ULTOIs who left a rigid religious group presented more physical symptoms than other ex-ULTOIs (Fenelon & Danielsen, 2016). Indeed, a small number of studies conducted among ex-ULTOIs have found many reporting high levels of stress, loneliness, and suicidal ideation during the process of leaving the community (Davidman & Greil, 2007; Doron, 2013; Engelman et al., 2020).

Interestingly, whereas most ex-ULTOIs experience difficulties and psychological distress through the disaffiliation process, many manage to adapt and build a fulfilling life in the aftermath of the process (Davidman, 2015; Weiskopf, 2016). The potential for a fulfilling life notwithstanding, Horowitz (2018), in his qualitative study, suggested that some have more difficulty coping with disaffiliation, even coming to extreme risk situations and suicidal behaviour. However, to our knowledge, no quantitative study has investigated the psychological distress among ex-ULTOIs, leaving the prevalence of mental pain and mental disorders in this group unclear. Moreover, little is known concerning the risk and the protective factors that may facilitate overcoming the challenges during the disaffiliation process. In this study, we sought to fill these gaps through a quantitative examination of the psychological distress ex-ULTOIs may face and identify risk factors contributing to the described psychopathologies.

The varying degrees of distress among ex-ULTOIs and their ability to adjust can be partly explained by their early experiences within their Orthodox community. Immigration studies have found that difficulties in the country of origin and traumatic events before or during immigration are associated with adjustment difficulties, depression, and suicide (Bursztein Lipsicas et al., 2012; Forte et al., 2018), and evidence for a comparable pattern has been found among ex-ULTOIs (Horowitz, 2018). Thus, ex-ULTOIs having a traumatic history that may have motivated disaffiliation could be at increased risk of psychological distress and suicide.

Various factors and circumstances for leaving the ultra-Orthodox lifestyle can also contribute to the degree of distress experienced by ex-ULTOIs. Immigration studies have described the psychological trajectories of immigration as including elements related to the culture of origin that push the person out of his community (e.g. stressful life events) and to the culture of destination that pull the person to the target culture (e.g. economic opportunities; Parkins, 2010). These studies have found that the degree to which push and pull factors characterize the immigration process impacts the immigrant's mental well-being, integration, and acculturation (Hodge, 2014). Specifically, push factors have generally been associated with increased adjustment difficulties, depression, and suicide, whereas pull factors have been associated with improved well-being (Forte et al., 2018). Regarding ex-ULTOIs, qualitative studies have identified various triggers driving them to leave their home communities. For some, the disaffiliation process was driven by their aspiration for personal autonomy or a desire for authentic self-fulfilment (Doron, 2013; Engelman et al., 2020). For others, disaffiliation was triggered by wanting to escape situations of sexual abuse, violence, or rejection (Cappell & Lang, 2020; Fenelon & Danielsen, 2016).

Horowitz (2018), investigating ex-ULTOIs through interviews using a narrative approach, distinguished between spontaneous disaffiliation (e.g. a hasty exit following a crisis) and strategic disaffiliation (e.g. a gradual, measured process after deliberation and preparation), finding relatively more resilience among strategic ex-ULTOIs. In contrast, the ex-ULTOIs who experienced trauma, endured other mental difficulties, and were treated with psychiatric medication before leaving ultra-Orthodox society were more likely to present suicidal ideation.

The current study

Qualitative studies have addressed the difficulties and distress faced by ex-ULTOIs, their complex relationships within the Orthodox community, and their experience of transparent immigration (Berger, 2015; Cappell & Lang, 2020; Weiskopf, 2016). To our knowledge, the prevalence and levels of mental pain and psychopathology in this group have not been quantitatively measured, nor have various disaffiliation process variables been examined as contributors to their mental pain. In this study, we sought to shed light on the psychological distress experienced by ex-ULTOIs and identify factors that may facilitate higher levels of distress. Thus, these findings would aid in identifying those needing psychological help and assistance.

Specifically, our aims were the following:

1. To assess to what extent ex-ULTOIs experience depression, anxiety, PTSD symptoms, and suicidal ideation in the aftermath of the disaffiliation process.

2. To examine the contribution of disaffiliation process variables (i.e. pre-migration life events and characteristics of the disaffiliation process) to ex-ULTOIs’ level of mental pain.

Method

Participants

Participants comprised 896 Israeli individuals who had left ultra-Orthodox Jewish communities and were now members of Israel Hillel, a non-profit organization that provides support services to individuals who leave Orthodox Jewish communities. Inclusion criteria were those over 18 who disaffiliated from ultra-Orthodox communities within the last 25 years. Of all 896 participants who agreed to participate, 111 (12.39%) did not complete the bulk of the study questionnaires, and three (0.34%) did not meet the inclusion criteria. The remaining 755 participants (84.26%) completed all or most questionnaires (their demographics are presented in Table 1). Participants’ mean age was 27.71 (SD = 5.11), whereas their mean age when leaving their Orthodox communities was 20.28 (SD = 1.84). Of the participants, 46.5% (n = 350) were female, 51.9% (n = 392) were male, and 1.7% (n = 13) did not identify as male or female. Furthermore, 64.5% (n = 487) were single, 14.8% (n = 112) were married, and 14% (n = 106) were divorced; 21.7% (n = 164) were parents, and most of these (73%) had full custody of their children. Regarding schooling, 38.8% (n = 289) had not completed 12 years of school, 20.3% (n = 151) completed high school, 10.5% (n = 78) had acquired professional education, and 30.4% (n = 226) held an academic degree. Regarding employment, 38.3% (n = 288) worked full-time, 32.9% (n = 247) worked part-time, and 28.3% (n = 216) were unemployed. To examine the representativeness of the study sample to Hillel members, we compared the participants’ demographic data to the demographic data of the entire Hillel membership (provided by the Hillel organization chairman). We found no significant differences between the two groups regarding age, gender, education level, marital status, and employment Table 2.

Table 1. Demographics of the sample (N = 742).

Demographic variable	Sub-groups	Frequency	Percentage	Range	Mean	SD
Age				19–54	27.71	5.11
Gender	Male	392	52.8
	Female	350	47.2
Orthodox stream	Lithuanian	278	37.9
	Hasidic	210	28.6
	Sfaradim	206	28.1
	Modern ultra-Orthodox	39	5.3
Education	Less than 12 Years	289	38.8
	High school matriculation	151	20.3
	Professional education	78	10.5
	Academic education	226	30.4
Employment	Unemployed	216	28.8
	Part-time	247	32.9
	Full-time	288	38.3
Family status	Single	487	64.5
	Engaged	22	2.9
	Married	112	14.8
	Divorced	106	14.0
	Other	28	3.7
Children	Yes	164	21.7
	No	591	78.3
Children - number				0–6	.40	.90
Children - relationship	Full custody	119	73.0
	Partial custody	16	9.8
	Meet often	15	9.2
	Rarely meet	5	3.1
	Not in touch	8	4.9

Table 2. Characteristics of the participants’ disaffiliation process (N = 742).

Disaffiliation process variables	Sub-categories	n	Percentage	Range	Mean	SD
Family status in disaffiliation	Single	612	81.3
	Married	61	8.1
	Engaged	3	.4
	Divorced	68	9.0
	Separated	9	1.2
Process partner	Alone	493	65.9
	With partner(s)	255	34.1
Familiarity with secular culture				0–10	3.95	2.73
Process duration (after deciding to disaffiliate)	A few weeks	126	16.8
	A few months	111	14.8
	About a year	179	23.9
	Two to three years	209	27.9
	Four to seven years	100	13.4
	Over seven years	23	3.1
Current religious affiliation	Religious(non-ultra-Orthodox)	17	2.3
	Traditional	91	12.2
	Secular	528	71.0
	Undefined	108	14.5

Regarding disaffiliation process-related characteristics, 65.9% (n = 493) of the participants had no partner when leaving their community. Of the participants, 16.8% (n = 133) reported a disaffiliation process that lasted a few weeks, 14.6% (n = 115) reported a duration of a few months, 23.7% (n = 187) reported a one-year process, 28.1% (n = 222) reported two to three years, 13.8% (n = 109) reported five years, and 3% (n = 24) reported 10 years. Most participants (n = 563, 71.2%) identified as secular, 14.6% (n = 115) reported subscribing to varying degrees of affiliation with Judaism, and 14.5% (n = 108) did not define their religious affiliation.

Measures

The Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2009). The PHQ-9 was used to measure the prevalent symptoms among the diagnostic criteria for major depressive disorder (e.g. anhedonia, depressed mood, disturbances in sleep and appetite, self-disparagement, and psychomotor agitation). The PHQ-9 is a widely used instrument for recording the frequency of depressive symptoms over the past month, presented on a 4-point Likert-type scale, ranging from 0 (not at all) to 3 (nearly every day). The total score comprised the sum of the nine items. In this study, we used the PHQ-9 total score as a continuous variable in our analyses and as an indication of a major depressive disorder, using the validated cutoff value of ≥ 10 (Manea et al., 2012). Cronbach's alpha coefficient for the current sample was α = .88.

The Generalized Anxiety Disorder 7 (GAD-7; Spitzer et al., 2006). The GAD-7 is a 7-item self-report scale measuring the frequency of anxiety symptoms over the last two weeks (e.g. ‘Feeling nervous, anxious, or on edge’), presented on a 4-point Likert-type scale ranging from 0 (not at all) to 3 (nearly every day). Items are summed to yield a total score ranging from 0 to 21, with higher scores indicating more anxiety symptoms. The GAD-7 has good sensitivity and specificity for particular anxiety disorders. The severity cutoff point for moderate and severe anxiety is 10. In this study, we used the total score as a continuous variable and as an indication of generalized anxiety disorder using the validated cutoff of ≥ 10 (Plummer et al., 2016). Cronbach's alpha coefficient for the current sample was α = .93.

The PTSD Checklist (PCL-5; Blevins et al., 2015). Participants’ PTSD symptoms were assessed with the PCL-5, which taps the 20 symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition DSM-IV (American Psychiatric Association, 2013). Participants were asked to rate how often they suffered from each symptom over the previous month on a 5-point Likert-type scale, ranging from 0 (not at all) to 4 (frequently). Specifically, participants were asked about their reactions to any particularly stressful experiences they had undergone (e.g. ‘I have recurrent dreams and nightmares about a stressful event I experienced’). We used this scale as a continuous variable by summing the scores for the 20 items (range 0–80; Blevins et al., 2015) and as a dichotomized DSM probable self-rated ‘diagnosis’ (Ghazali & Chen, 2018). Participants were classified as having PTSD if they reported a value greater than the PCL-5 cutoff of 33 (Weathers et al., 2013). Findings revealed impressive psychometric properties for the PCL-5 (Blevins et al., 2015); the PCL-5’s reliability for the current sample was α = .96.

Suicide Behaviours Questionnaire-Revised (SBQ-R; Osman et al., 2001). SBQ-R was used to assess participants’ current suicide ideation with four items tapping suicide attempts in the past, current suicide ideation, suicide threats, and perceived likability to die by suicide in the future. In this study, we used only Item 2 of the SBQ-R (‘How often have you thought about killing yourself over the past year?’), which assesses the frequency of current suicidal ideation. Several studies have employed a single item to assess suicidality, specifically using SBQ-R's Item 2 to assess current suicide ideation (Teismann et al., 2018; Zerach & Levi-Belz, 2018). Moreover, there is strong evidence for the predictive ability and relevance of a single item to assess suicidality (Green et al., 2015; Simon et al., 2013). SBQ-R's Item 2 is scored on a 5-point Likert-type scale, ranging from 1 (Never) to 5 (Very often).

Push and Pull Measures (Engelman et al., 2020). This 14-item questionnaire measures possible reasons for leaving one’s community. Six items assessed reasons related to aspects within the ultra-Orthodox culture that motivated disaffiliation (Push: e.g. ‘When I grew up in the ultra-Orthodox community, I felt that I just didn't fit in’); eight items measured causes related to aspects of non-Orthodox culture that attracted them (Pull: e.g. ‘I wanted to leave the ultra-Orthodox community to receive a secular education and seek an opportunity for a good and independent livelihood’). The questionnaire items were presented on a 5-point Likert-type scale, ranging from 1 (strongly disagree) to 5 (strongly agree). In this study, scores were calculated for the two scales by summing the scores for the scale items. The questionnaire has been found to have adequate internal reliability (Engelman et al., 2020). For the current sample, Cronbach's alpha coefficient was α = .71 for the Push scale and α = .71 for the Pull scale.

The Life Events Checklist (LEC; Gray et al., 2004). The LEC was used to measure participants’ exposure to 13 potentially traumatic events (e.g. ‘Physical assault for example, being attacked, hit, slapped, kicked, beaten up’), presented on a 5-point Likert-type scale, ranging from 1 (Happened to me) to 5 (Doesn't apply to me). The original LEC comprises 16 items, but we used only the 14 items related to the current sample and adapted it for ex-ULTOIs. Items were summed to yield a total score of traumatic events exposure, ranging from 1 to 70, with higher scores indicating greater exposure to stressful life events. The LEC is a widely used self-report screening measure tapping trauma history, though not intended to meet DSM-IV diagnostic criteria for traumatic exposure (Gray et al., 2004). The questionnaire exhibited good convergence with an established measure of trauma history and significantly correlated in the predicted directions with measures of psychological distress and PTSD symptoms (Gray et al., 2004).

Socio-demographic and disaffiliation-related characteristics. We assessed demographic characteristics, including family status, religious orientation, age, gender, educational level, and Orthodox stream. Features of the participants’ disaffiliation process were also assessed, including process duration, process partners, level of preparation, and participants’ experience of disaffiliation (as trauma or crisis).

Procedure

The Ruppin Academic Centre internal review board approved this study. Participants were recruited via email sent to the membership lists of the Israel Hillel organization, the primary organization providing support services to individuals who have left the ultra-Orthodox world. To enlarge the study sample, we sent three emails at 2-week intervals noting the compensation offered to participants. Moreover, we also advertised the study on social media sites without explicitly delineating its aims. Participants agreeing to participate were required to affirm their willingness to participate by signing an informed consent form and then completing the online questionnaire (using the Qualtrics online data collection platform). After completing the survey, participants were compensated with a voucher (approximate value: US$10). Altogether, invitations were sent to all Hillel organization members (approximately 2000 registered members), with 896 Ex-ULTOIs participating in this study. The response rate of 45% is considered high for organizations (e.g. Baruch & Holtom, 2008). Thus, it can be suggested that while the study sample is insufficient for establishing prevalence rates of psychopathology due to the response rate, it can be considered an important first step in understanding the mental health issues of this population.

Statistical analysis

First, we computed descriptive statistics of demographic and questionnaire data. Second, the associations between the study variables were examined in a series of Pearson correlation analyses. Third, to address the unique contribution of the disaffiliation process features, four six-step hierarchical regression analyses were conducted with PHQ-9, GAD-7, PCL, and current SI as dependent variables.

For each regression, we entered measures of gender and age as covariates in the first step. In the second step, we entered negative life events. In the third step, we entered the time since the participant left their Orthodox community. In the fourth step, we entered variables related to the disaffiliation process, the duration of the process, having a partner (or not) when leaving, and the degree of familiarity with the secular culture before leaving. In the fifth step, we entered measures of the degree to which participants experienced disaffiliation as a traumatic event and as a response to a crisis. In the sixth step, we entered the Push and Pull measures.

Results

Prevalence of depression, anxiety, PTSD, and suicidal ideation among ex-ULTOIs

In this section, we calculated descriptive statistics and rates of distress measures among the participants. As presented in Figure 1, a high prevalence of participants met the criteria of depression, anxiety, PTSD symptoms, and SI, as measured by a self-report diagnosis and validated cutoffs. The PHQ-9 revealed the incidence of current depression at 45.9% (n = 332), and the GAD-7 revealed anxiety symptoms of clinical significance among 27.1% (n = 189) of the sample. Among the participants, 46.7% (n = 303) exceeded the PCL-5 cutoff score of 33 anchored to stressful experiences before and during disaffiliation according to the DSM-5 (APA, 2013) criteria. Regarding current SI, 34.5% (n = 241) scored above the pre-specified cutoff score for SI and were classified as suicidal ideators; 21.6% of these reported low SI frequency (n = 151), and 12.9% (n = 90) revealed high SI frequency.

Figure 1. Percentage of self-reported mental disorders in the study sample (N = 755).

Disaffiliation processes’ characteristics as contributors to distress levels among ex-ULTOI

Preliminary analysis. To test the hypothesis that variables related to the disaffiliation process contributed to distress measures, correlations between the study variables were calculated. The means, standard deviations, ranges, and intercorrelations are presented in Table 3. The matrix indicates that the LEC and the Push and Pull measures (disaffiliation as trauma and crisis-related) were positively related to all outcome measures. Moreover, having a partner during the disaffiliation process was negatively correlated to all outcome measures, and the degree of familiarity with the secular culture before leaving was negatively correlated with PTSD symptoms.

Table 3. Pearson correlation coefficients between disassociation process-related variables and mental health measures (N = 744).

	1	2	3	4	5	6	7	8	9	10	11	12
1. Time since exit (years)	1
2. Process partner (Yes)	−.02	1
3. Pushed out reasons	.05	−.12**	1
4. Pulled out reasons	.10**	−.07	.55**	1
5. Secular culture familiarity	−.11**	.07*	−.16**	−.04	1
6. Exit as a traumatic experience	.10**	−.09*	.34**	.17**	−.23**	1
7. Crisis-related exit	.03	−.07	.56**	.21**	−.14**	.35**	1
8. LEC	.05	−.04	.34**	.22**	−.15**	.21**	.39**	1
9. PHQ9	−.08*	−.18**	.33**	.21**	−.04	.27**	.30**	.35**	1
10. GAD7	−.07	−.09*	.30**	.21**	−.06	.26**	.28**	.38**	.68**	1
11. PCL	−.05	−.13**	.41**	.25**	−.14**	.34**	.39**	.48**	.65**	.61**	1
12. SI	−.06	−.15**	.17**	.09*	−.04	.19**	.20**	.27**	.53**	.43**	.44**	1
M	7.45	1.34	21.39	48.51	3.95	3.13	2.70	34.97	10.09	6.60	29.45	1.76
SD	4.49	.47	9.20	13.29	2.73	2.00	2.15	12.01	6.99	6.06	22.17	1.25
Min-Max	0–25	1–2	5–40	9–72	0–10	1–7	1–7	1–70	0–27	0–21	0–80	1–5

Note. *p < .05. **p < .01. ***p < .001; PHQ9 = Patient Health Questionnaire; GAD7 =  General Anxiety Disorder; PCL = the PTSD checklist; SI = current suicide ideation (Suicide Behaviours Questionnaire-Revised; SBQ-R; Item 2).

Hierarchical regression analyses. To determine if the variables related to the disaffiliation process contribute to depression, anxiety, PTSD symptoms, and SI levels beyond the demographics, we conducted four multiple hierarchical regression analyses, with mental pain measures as the dependent variables.

The four regression equation designs comprised six steps, each with the same variables. Each variable’s contribution to the regression is presented in Table 4. The entire set of variables in the final model explained 23.5% of the variance for PHQ-9, F _(11,682) = 19.03, p < .001; 22.6% for GAD-7, F_(11,654) = 17.39, p < .001; 35.4% for PCL, F_(11,664) = 30.02, p < .001; and 11.4% for SBQ-R-Item 2, F_(11,656) = 7.68, p < .001.

Table 4. Four hierarchical regressions predicting mental health measures by study variables (N = 755).

		PHQ_9				GAD7				PCL				SI
Step	Predictors entered in each step:	B	t	Beta	ΔR2	B	t	Beta	ΔR2	B	t	Beta	ΔR2	B	t	Beta	ΔR2
1	Gender (male = 0; female = 1)	2.37	4.57	.17***	.03***	2.61	5.72	.22***	.05***	9.90	6.04	.23***	.06***	.20	2.13	.08*	.01
	Age	−.11	−2.07	−.08*		−.11	−2.36	−.09*		−.31	−1.92	−.07		−.00	−.44	−.02
2	LEC	.19	8.75	.32***	.10***	.18	9.73	.35***	.12***	.81	12.79	.44***	.18***	.03	6.50	.25***	.06***
3	Time since exit	−.13	−1.92	−.09	.01	−.07	−.13	−.05	.00	−.18	−.87	−.03	.00	−.02	−1.92	−.09	.01
4	Process partner	−2.47	−4.85	−.17***	.03***	−.81	−1.82	−.06	.00	−4.71	−3.09	−.10**	.02***	−.34	−3.57	−.13***	.02**
	Process duration	.25	1.40	.05		.08	.53	.02		1.01	1.86	.06		.04	1.05	.04
	Secular culture	.03	.33	.01		−.06	−.71	−.03		−.65	−2.34	0.08**		.00	.28	.01
5	Exit as a traumatic experience	.62	4.74	.18***	.05***	.51	4.41	.167***	.04***	2.09	5.45	.19***	.07***	.08	3.21	.13**	.02***
	Crisis-related exit	.42	3.31	.13**		.22	1.94	.08		1.77	4.76	.17***		.04	1.59	.07
6	Pushed out reasons	.42	2.26	.11*	.02**	.22	1.31	.07	.01**	1.61	2.92	.13**	.02***	.01	.19	.01	.00
	Pulled out reasons	.27	1.36	.06		.30	1.67	.07		.71	1.21	.05		.01	.37	.02

Note. *p < .05. **p < .01. ***p < .001; LEC = Life Events Checklist; PHQ9  = Patient Health Questionnaire; GAD7 = General Anxiety Disorder; PCL = the PTSD checklist; SI = current suicide ideation (Suicide Behaviours Questionnaire-Revised; SBQ-R; Item 2).

As seen in Table 4, gender, entered in Step 1, demonstrated a significant contribution to the explained variance for PHQ-9, GAD-7, and PCL-5 (β = .17, β = .22, β = .23, respectively). Age, also entered in Step 1, showed a significant negative contribution for PHQ-9 (β = −.08) and GAD-7 (β = −.09). LEC, entered in Step 2, contributed positively to all outcome measures ⁣⁣beyond the demographics. Time since the disaffiliation, entered in Step 3, had no significant contribution to the explained variance for all the outcome measures beyond the demographics and LEC. Disaffiliation-related variables (partner during the process, duration of the process, and degree of acquaintance with the secular society before leaving), entered in Step 4, contributed significantly to the explained variance of PHQ-9, F_(3,686) = 8.72, p < .001; PCL-5, F_(3,668) = 6.82, p < .001; and SBQ-R-2, F_(3,660) = 4.70, p = .003. Specifically, having a partner during the disaffiliation process contributed positively to PHQ-9, PTSD symptoms, and SI (β = −.17, β = −.10, and β = −.13, respectively), and familiarity with the secular culture before disaffiliation contributed positively to PTSD symptoms (β = .08). Process experience measures (disaffiliation perceived as trauma and crisis, entered in Step 5, also contributed positively to PHQ-9, F_(2,684) = 22.85, p < .001); GAD-7, F_(2,656) = 14.98, p < .000; PCL-5, F_(2,666) = 35.726, p < .001; and SBQ-R-2, F_{(2, 658)} = 8.42, p < .001. Specifically, experiencing disaffiliation as a traumatic event was found significant for all distress measures (β_PHQ-9 = .18, β_GAD-7 = .17, β_PCL-5= .19, and β_SBQ-R-2= .13). Finally, Push and Pull measures, entered in Step 6, had a positive contribution to the explained variance of PHQ-9 5, F_(2,682) = 6.92, p = .001; GAD-7 5, F_(2,654) = 4.71, p = .009; PCL-5, F_(2,664) = 9.46, p < .000; but not SBQ-R-2. Specifically, the Push measure contributed positively to PHQ-9 (β = .11) and PTSD symptoms (β = .13).

Discussion

This study aimed to shed light on distress levels (i.e. depression, anxiety, PTSD symptoms, and current SI) and its contributors among ex-ultra-Orthodox Jews in Israel. Our findings demonstrate that ex-ULTOIs experience high distress levels, as manifested in their rates of depression, anxiety, PTSD, and suicide ideation. Nearly half of the sample suffered from depressive symptoms that met the criteria for major depressive disorder, and nearly half reported symptoms above the PTSD cutoff score. Moreover, a third of the sample reported having had suicidal thoughts in the past year. These numbers align with studies highlighting the emotional distress among disaffiliates (Davidman, 2015; Velan & Pinchas-Mizrachi, 2019). Importantly, the noted prevalence of mental disorders among ex-ULTOIs is substantially higher than that of representative samples of Israel’s general population: National statistics reveal lifetime depression at 10.6% (Kaplan et al., 2010), and reporting for the last 12 months yielded a 6% incidence of depression and a 2% incidence of general anxiety symptoms (Levinson et al., 2007). PTSD symptoms have been reported by 9% of the general population (Ben-Ezra et al., 2018). Thus, the high prevalence of mental disorders underscores the need for significant interventions to help these individuals cope with the disaffiliation process.

Our findings reveal that disaffiliation processes and their features contributed to the noted ex-ULTOIs’ distress levels. Specifically, stressful life events before and during disaffiliation manifested the strongest contribution to elevated levels of distress. Moreover, stronger experiences of being ‘pushed out’ of the ultra-Orthodox community following those stressful experiences were associated with higher levels of depression and PTSD. Ex-ULTOIs who underwent the process with a partner (i.e. a friend or family member) reported lower distress levels. Furthermore, ex-ULTOIs whose disaffiliation process extended to seven years and more reported higher levels of depression and PTSD symptoms.

We also found that the participants’ reflective experience contributed to psychological distress. Specifically, those experiencing their disaffiliation as traumatic reported significantly higher levels of distress. Furthermore, we found that SI related to the participants’ current religious identity: Those who did not specify their current religious identity reported more frequent SI than participants who identified as religious, traditional, or secular.

In light of our findings, ex-ULTOIs appear to experience high distress levels exceeding those described in studies on immigrants and other high-risk groups (Aragona et al., 2012; Browne et al., 2017; Turecki et al., 2019) as well as on representative samples of adults in Israel (e.g. Ben-Ezra et al., 2018). These findings beg the question: How can the impact of disaffiliation-related features be explained? We will offer several possibilities.

Firstly, the high levels of distress demonstrated by the current participants may be a manifestation of the long-term effect of traumatic events that transpired within the ultra-Orthodox community before or during disaffiliation. Immigration studies have reported that immigrants’ traumatic experiences tend to be interrelated and cumulative; thus, those with a traumatic history face more resettlement difficulties and are more vulnerable to new traumas (Aragona et al., 2012; Forte et al., 2018; Kene et al., 2016a), a dynamic that may also be true for ex-ULTOIs. Indeed, we found that past traumatic life events were associated with higher distress levels, as well as the attribution of traumatic events to the decision to leave. Many participants defined their disaffiliation process as traumatic and presented elevated distress levels. That is, ex-ULTOIs appear to affiliate with the secular society in a vulnerable state, stemming not only from the complex cultural transition but also from the impact of a traumatic history, to which a traumatic transition to Israeli society is supplemented.

Our findings showed gender to be associated with distress levels: women presented higher levels of distress. Relative to men, the women in the current sample reported enduring more traumatic events in their past, and in light of this finding, their increased distress does not surprise. Greater distress was also reported by participants whose disaffiliation process was exceptionally long (above seven years) and by those who did not define the nature of their religious identity.

Berry's (2001) acculturation model can aid in understanding these findings. This model suggests that immigrants’ identification with their culture of origin and their new host culture contributes to their psychological well-being; thus, immigrants with low identification with both cultures are at higher risk for mental distress (Berry, 2001). Applying the acculturation model to ex-ULTOIs, those with low identification with both their former and new cultures can be considered ‘marginal’ and are likely to encounter relatively more adjustment challenges and mental distress. Thus, the acute distress among ex-ULTOIs in our study may stem from the ambivalent experience characterizing such a transition between cultures, which requires adopting an integrative identity (Sonnenschein, 2017). Specifically, the protracted transition process and indefinite religious identity may be indicative of a marginalized group experiencing difficulties forming an integrative sense of identity that incorporates elements from both cultures, resulting in increased distress.

The push and pull factors as contributors to distress levels among ex-ULTOIs

Our findings revealed that push, but not pull, factors predicted increased levels of distress beyond the effects of traumatic life events. Whereas pull factors have been shown to be associated with distress levels in studies of immigrants (Hodge, 2014), our findings aligned with Engleman et al. (2020), who investigated Orthodox disaffiliates. Thus, while pull aspects constitute a protective factor for immigrants, they do not play a similar role in the disaffiliation process. in the case of immigrants. For immigrants, the pull of economic conditions and other opportunities will likely play a significant role in their adjustment. For disaffiliates, however, push factors related to life within their community of origin (e.g. interpersonal traumas and experiences of rejection or disappointment) are likely to play a significant role in their decision to leave. Thus, for ex-ULTOIs, push and pull factors may trigger a different type of distress.

The contribution of push factors can be explained by Thomas Joiner’s well-known interpersonal theory of suicide (IPT), which highlights the role of interpersonal stressors, including family conflict and social isolation, in suicidal ideation (Joiner et al., 2009; Van Orden et al., 2011). IPT holds that push factors associated with the experiences of loneliness, burdensomeness, and lack of belonging––including lack of belonging within secular society––comprise a significant source of distress. This liminal state contributes to a sense of being ‘in-between,’ evoking feelings of alienation toward both their ultra-Orthodox community, often a source of rejection or exclusion (Davidman, 2015), and the secular society, in which they feel foreign and strange (Cappell & Lang, 2020; Doron, 2013). The centrality of interpersonal factors in distress levels is supported by our finding that participants whose disaffiliation was made with a partner (i.e. a friend or family member) reported lower levels of distress. IPT, then, would hold that when disaffiliation transpires in an interpersonal context, the individual retains a sense of belongingness that can provide them with an element of protection from distress and suicide ideation (e.g. Levi-Belz & Aisenberg, 2021).

This study's results should be carefully considered in light of several important methodological limitations. First, the directionality of the associations found among the variables remains undetermined, given the cross-sectional nature of the data. The correlational research design further precludes drawing any causal inference regarding the relations among the variables. For example, individuals more prone to depressive symptoms or suicidal ideations may find themselves more engaged in conflict and traumatic events related to their disaffiliation processes. Thus, the source of the reported distress, whether before or during the disaffiliation, remains inconclusive. Given the preliminary nature of our findings, prospective longitudinal studies are recommended for further research to determine causality.

Second, the data regarding mental health and disaffiliation processes were obtained using retrospective self-report measures, which can introduce a recognized range of biases, such as those related to mood-dependent recall, forgetting, cathartic effect, and social desirability. Future studies should consider employing objective measures, such as observation of actual functioning.

Third, we capitalized on a non-representative sample derived from the Israel Hillel organization’s membership. Whereas the response rate was quite high (45%), our sample may still not represent the actual ex-ULTOI population. Thus, the current participants may differ in some measure (e.g. psychological distress levels) compared with ex-ULTOIs who did not participate. A broader and more representative sample of ex-ULTOIs would facilitate a fuller understanding of their distress trajectories over time.

Theoretical and practical implications

Our findings have both theoretical and practical implications. Theoretically, these results highlight that disaffiliation, like immigration, can be considered a risk factor for psychological distress. Ex-ULTOIs migrate from a closed conservative culture to an open postmodern culture, a process often characterized by long periods of intrapersonal debate and hiding, followed by varying degrees of disconnection from the original environment and by sensations such as shame and guilt (Davidman & Greil, 2007; Doron, 2013; Zalman, 2021). These features of the disaffiliation process can help explain the extremely high prevalence of the ex-ULTOIs’ mental distress, as revealed in qualitative studies (Berger, 2015; Cappell & Lang, 2020; Sonnenschein, 2017) and as emerging from the current quantitative findings. Similar to the dynamics of immigration (Chou, 2009; Schweitzer et al., 2006), characteristics of the disaffiliation process are likely to impact ex-ULTOIs’ current distress levels.

These findings highlight the importance of the context in which the disaffiliation transpired and how it was experienced as factors crucial to determining the ex-ULTOIs’ distress level, regardless of the time elapsed since their exit. Specifically, it would appear that ex-ULTOIs are likely to endure more serious mental distress if their exit occurs in the wake of traumatic life events, is protracted, and is experienced as traumatic. Moreover, the ambivalence characterizing disaffiliation, when protracted or even chronic, may exacerbate the ex-ULTOIs’ distress. Thus, the experienced distress and adjustment difficulties may stem from a traumatic history followed by a difficult, complex journey, after which ex-ULTOIs are left to struggle with identity confusion.

Regarding practical implications, the study’s findings highlight the importance of addressing disaffiliation as a risk factor for psychological distress in general and depression and SI specifically. The severity of the psychological difficulties and the fact that some experience symptoms even years after disaffiliation stress the importance of screening for PTSD symptoms, depression, and SI to provide the appropriate treatment in a timely fashion. Clinicians should consider the ex-ULTOIs’ cultural transition and assess their perception of the process since, as with immigration (Kene et al., 2016b), this perception was found significant for their mental health. It is also critical for clinicians to examine the ex-ULTOIs’ efforts to cope with the challenges of adaptation and resettlement, review their personal history, and help them form an integrative sense of identity. Treatments such as interpersonal psychotherapy (Markowitz & Weissman, 2004) can address ex-ULTOIs’ need to create and strengthen interpersonal relationships and process those that remained or were severed. They would likely benefit from group therapies that can support and normalize the emotional difficulties they experience (Hernández-Plaza et al., 2006). Moreover, as disaffiliation appears to comprise a long-term trauma with wide-ranging consequences, PTSD-focused treatments, such as prolonged exposure (PE) or cognitive processing therapy (CPT), may be effective for coping with ongoing traumatic events, thus reducing PTSD and suicide ideation among this at-risk population (Gradus et al., 2013).

Author statement contributors

YLB and SY designed the study and analyzed the data. SY wrote the final manuscript. Both authors approved the final article.

Acknowledgments

We deeply thank the Efrati Family for their generous support. We thank Liron Orbach from the Israel Hillel organization for her contribution to recruiting the participants to this project.

Data availability statement

The data supporting this study's findings are available on request from the corresponding author [YLB].

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Efrati Family [grant no. 11 in memory of Dror Efrati]; Path to Life [grant no. 145 i- To Shacar Yalon].