An Amish Paradox

by Charles E. Hurst

  Natural, over-the-counter, multiple-use, unregulated remedies constitute a significant portion of health care treatment among the Amish. Photograph courtesy of Charles Hurst.

  Another traditional belief was described to us by an M.D. He told of a Swartzentruber man who brought his son in with appendicitis after trying a traditional approach in which he had had “his son crawling down the steps head first.” He thought that since the appendix hung below the colon, if the child was turned upside down, the appendix would drain. Puzzled, he told the driver taking him to the hospital: “I don’t understand why this is happening; we carried him up and down the stairs backwards all morning.” A third traditional belief is the “nail clipper” theory, which holds that if you tie a nail clipper to the end of a string and dangle it above a group of pills in your hand, for example, whether and how the clipper moves will tell the person which pills will or won’t work. Many such traditional beliefs are seen as myths or “old wives’ fables” by most New Order Amish. Adherence to them is most likely among very conservative groups. Religion is sometimes entangled with healing beliefs as well, as in the following example from the Budget: “To stop bleeding read Ezekiel 16th chapter, verse 6. Repeat 3 times then read it backwards.”29

  When it comes to mainstream medical approaches, commented a physician, “[the Amish] have a healthy skepticism … They’ve seen us prescribe medicines and then five years later say ‘No, you don’t want to take that medicine.’” Many Amish will try a treatment or medicine if the explanation for its proposed effects sounds logical and if there is someone they know with the same problem who has been helped by the treatment. However, there is a certain amount of general trust and gullibility that makes many Amish susceptible to smooth-talking charlatans, persuasive ads for new treatments, and questionable fads that allege to cure many if not most ailments. They rely more heavily than most others on the honesty of the person treating them. Local physicians say Amish vulnerability is due heavily to their lack of understanding of science and of how medicine really works. Marketing of products is doubly appealing to potential customers if the product is also reasonably priced.

  In sum, much of the attractiveness of alternative medical treatments lies in the common sense and understandable manner by which they are explained by practitioners who appear sincere and concerned about their patients. When mainstream treatments are clearly explained by trusted professionals, most Amish have little aversion to using them, especially if they can afford the costs and if some success can be demonstrated. There is no biblical or traditional basis for rejecting mainstream medicine out of hand. Rather, as their knowledge of the usefulness of modern medicine increases, more Amish, especially the less conservative orders, have availed themselves of it. The increased reliance upon local hospital and clinic facilities by the Holmes County and Wayne County Amish is evidenced by their negotiation with these institutions for lower prices (see the subsequent section titled “Paying for Health Care”).

  Psychological Well-Being among the Amish

  More is known about issues of physical health than about psychological difficulties among the Amish. One of the dangers in diagnosing psychological problems is that the standards of what is normal vary between Amish and English communities. Boys and girls are raised differently, are taught different values, and are socialized into different role expectations. The result is that a given attitude or behavior might be considered normal in one context but abnormal in another. The perceptions of issues like confidentiality, counselor-client relationships, sexual abuse, and the objective stance of the therapist can be interpreted differently within the context of Amish culture and religion.

  Working effectively with Amish clients “requires a profound shift in perceptions” on the part of English therapists.30 Misunderstanding Amish culture or imposing one’s own mental framework on it can result in the mislabeling of behaviors and demeanor. Some have even argued that mental illness is a social construction, that is, that its existence is determined by differences in cultural definitions of given behaviors.31 At least there is a danger that diagnoses can be culturally biased. A veteran M.D. who was raised Amish and has served the Amish for several decades noted that English physicians often err in diagnosing because they fail to understand the differences between English and Amish role expectations.

  Of course, misdiagnoses related to cultural biases and stereotypes are nothing new and have been found for other groups as well.32 What might be interpreted as being “withdrawn” by an outsider, for example, would be considered appropriate “reserve” by an Amish person. A good example of such misinterpretation is a case related by a physician who sent an Amish woman to a psychiatrist. When the physician asked how the visit went, she replied, “Well, he told me that I’m inhibited; I need to get rid of my inhibitions; I need to do this and that.” Then she said: “You know, when I sat down, he started telling me about his own life. If you think I have problems, he really has problems.” The physician, who has worked with the Amish for forty years and has an Amish background, concluded that “[the psychiatrist] didn’t understand her culture at all.” In a study of Amish and non-Amish women, Janet Fuchs and her colleagues found that Amish women were more likely to feel depressed and anxious, but they indicated that this result may be due to the greater willingness of Amish women to express some of these feelings because there is little stigma placed upon such expression.33 Consequently, some of the differences in well-being revealed in their research may not be real differences but rather artifacts of cultural differences. Gender beliefs may also be implicated. A recent study of Amish in Wayne and Holmes counties found that whereas more than three-fourths of the Amish women in the sample felt that the church was supportive when there was a need to seek mental-health treatment, most Amish men disagreed.34

  Since the early 1980s, there have been several attempts to identify a genetic origin of bipolar disorder within the Old Order Amish population, but these studies have yielded inconclusive results. Whatever genetic roots may exist are very complex and involve more than one gene.

  Generally, the rate of psychiatric illness among the Amish does not seem to be significantly different from that found in the general population. Most of the professionals we interviewed agreed with this conclusion. Several mentioned depression as the psychological problem they encounter most among Amish patients. But they did not think the Amish were more widely depressed than the non-Amish. Said a professional whom we asked whether depression rates were higher among the Amish: “No, I don’t think they are. I think they’re less, but when it happens it becomes kind of a major event … They’re not stress free; I’ll tell you that much.” “Depression is the biggest, most common mental illness we see … it’s not just Amish; it’s that generation of English people too,” said another physician. “They have the same illnesses everyone else does,” noted a veteran psychologist who works with Amish patients. Some research even points to lower levels of stress and depression among Amish women when compared to English women.35 However, as published studies have indicated, a local psychologist has found that genetics makes a difference in some cases. “There are certain families where the disorders run in the family.”

  There appear to be some differences tied to the various Amish orders in the kinds of issues raised by patients. Patients who are members of more conservative churches are more likely than other Amish to complain about issues related to authority and oppression. One therapist noted: “We’re more likely to hear from the Old Order … that they’re feeling oppressed by their clergy, or harassed by them. Or by the younger Old Order [members], we’ll hear stories about shunning and shaming a lot more … It becomes a real difficult struggle for these people, where they have to choose between their own personal beliefs and remaining part of their family. Whereas the Newer Order Amish, they don’t tend to shun.” Another physician expressed a similar view: “I see a lot more depressed patients in that group [conservative Old Order or Swartzentruber]. And I think because the ru
les are so strict, that some people just feel crushed underneath them.” While some adjust and accept the rules, “I think you have more in that group that struggle with depression and anxiety. There’s more of a sense of ‘I’m being watched and I don’t want to be watched.’”

  Further pressure is added because these symptoms also often have religious overtones. Adhering to strongly held beliefs can be difficult. Sarah Weaver, who was an Amish artist and invalid, depicted the choice and struggle associated with the narrow Amish way of life in her painting titled The Broad and Narrow Way. The “broad” way is the way of the world—easy, materialistic, hedonistic, immoral. The “narrow” way is the way of the righteous—difficult, Christian, humble, godly. The first leads to “eternal damnation,” but the second, though more demanding, leads to “eternal life.”

  Not surprisingly, behavioral indicators of psychological problems concern areas of central importance to the Amish lifestyle: dissatisfaction with work, religious doctrine, and not being married.36 Some of the sources of stress among the Amish originate in the discrepancies some feel between their actual behavior and attitudes, on the one hand, and the ideals expressed in their religious doctrines, on the other. “Maybe I feel like this because I haven’t submitted myself to Jesus or God enough. Maybe I have sinned,” is a refrain often heard by one psychologist. The Amish “think more of depression as a problem with spiritualness and your relationship with God,” said another doctor. This traditional interpretation is more likely among those Amish groups that have not changed much in their beliefs and lifestyles. For a church minister, the responsibility to enforce rules and deal with church problems can also cause stress. Other potential sources of anxiety include problems with members of the broader kinship group and economic difficulties. Some outsiders see the patriarchal structure of the Amish family as an added reason for stress among women.

  Amish life outside the home generates other stresses. “Farming is always a gamble,” noted one Amish man. Most Ohio Amish now work in nonfarm occupations and are often employed by others, a situation that creates different pressures from those encountered by farmers or the self-employed. Sometimes “it’s stress at work. Some can’t handle deadlines. Like I have one fellow,” observes one practitioner. “I think he’s the guy in charge of the business. But he’s got these phone calls, and he’s got people that want this right now, and they want this and they want that. He just goes bananas. He can’t handle that unless he’s taking some medication that keeps him calmed down.” Some see the higher incomes that often come with such work as a growing source of stress and anxiety. A change in the location where one works creates changes at home. Meals, especially breakfasts, for example, may not be taken together because of differences in the work schedules of family members. And other adjustments may need to be made. An Amish businessman also commented that daily devotionals may have to be moved from the morning to the evening because of occupational demands.

  The growing diversity of occupations has created some tension within the Holmes County Amish community. According to one source, Amish farmers “have complained a lot [because] people who aren’t on the farm have been given a lot more liberty than what they have … The guy who has the sawmill has fax machines; he’s got telephones … He’s got a cell phone. He’s not lacking much of anything … he’s been given a lot of freedom. And the farmer hasn’t been given all those.”

  Because the rules and living conditions vary within and between Amish orders, the kinds and degrees of stress and health problems experienced by their members would also be expected to vary. Groups that are more conservative and traditional, for example, the Swartzentruber Amish, may experience difficulties caused by the narrowness and implacable character of their Ordnung. Some Swartzentruber Amish will not work in town or may not go to a health professional if it means interacting with an ex-Amish person. For example, some Swartzentrubers told a well-known doctor who served an Amish community, “If she [an ex-Amish woman] works there, we can’t come there.” Strict rules place strict limitations on behavior. “I think sometimes too religious or too conservative religious practice can add stress rather than having a calming effect,” concludes one physician. For those who accept the rules, however, “there is a firm basis for making decisions that help minimize stress.” For those who don’t, for example, some youth, there are indicators of rebellion. A local psychiatrist made these comments: “[Old Order and Swartzentruber would say] the generation of people coming up are not as respectful; they’re arrogant, they’re stupid … I’ve got the new generation talking on the phone … And [the parents] know they have a problem, but they don’t know what to do with it. [The mixed consequences of] the narrow path and predictable path that their life will follow [is] the strength and weakness of their [Old Order] culture. The predictability is what makes it very comfortable to some people, but it’s also what makes it feel too confining to other people who want to break free of that.”

  New Order Amish, who tend to be more expansive in some cultural practices and who are more likely to have frequent contact with the English community and engage in nonagricultural labor, experience new sources of stress rooted in the changes they have adopted. At the same time, the higher level of flexibility creates an avenue for the reduction of stress. The features that distinguish the orders are thus two-edged swords. Flexibility may create more choices and minimize some sources of stress, but it may also introduce new problems to which individuals are unaccustomed.

  Cultural differences and the effort to maintain boundaries separating themselves from outside society sometimes hinder the Amish from seeking help for psychological difficulties.37 When they do seek help for such difficulties, they may turn to church leaders or Amish counselors before going to a professional outside their community. The training received by Amish counselors most likely has come from Mennonite counselors or Mennonite workshops they have attended. The Amish do not have formal licenses or degrees in psychotherapy. Among Old Order Amish, it has been found that the need to maintain a boundary between their community and the outside has discouraged members from seeking psychological help from mental-health professionals.38

  Amish counseling is biblically based; that is, there is a belief that following biblical lessons will teach one the truth, and “the truth shall make you free.” Most of the problems people have “are the same now as in Eden,” observes an Amish counselor. “Now if Christ is on the throne of the heart [instead of one’s self], he can control our thoughts and will. Then our feelings fall into place bringing peace … The only way one can function properly is to function with God[;] when the conscience is clear, the Spirit controls the will and emotions. This is the ultimate goal of counseling.”39 It is self-centeredness and selfishness that lead to fear, which in turn leads to emotional difficulties like depression and anxiety. To be healed, individuals have to shift their focus from themselves to God and others.40 In effect, for a person to become mentally healed, his or her own attitude and behavior must change. The source of difficulty is believed to lie within the person rather than in others or in the wider environment.

  Few Amish facilities focus on mental-health assistance for the Amish. A Holmes County center for treating emotional problems among the Amish opened in 1999 after one of the bishops realized that a relative needed counseling. The facility itself is unassuming, reflecting Amish values of humility and selflessness, and looks like a typical farm house; it has no sign in front to identify it as a place for counseling. The property also contains a small cabin, where couples can meet to work out problems, and a barn in which hands-on projects are completed by patients. The specific functions of the center, as set forth in its “statement of purpose,” are (1) “to support the growth and well-being of the Church”; (2) “to offer guidance and support to those persons and their families who are faced with mental and emotional health needs”; (3) to aid in the recovery of persons who have received medical or psychiatric help, so that they can “continue the healing process in a
Christian environment compatible to the ideals of the Church”; and (4) “to offer Biblical guidance for the prevention of serious mental illness.”41 Only four women at a time are taken in as residents, but “walk-ins” also come in for counseling, and these can be men or women. In 2001 the center had sixty-six cases, including walk-ins. A typical day for residents includes attending a Bible session and an advisory or therapeutic session with two counselors, carrying out assigned chores around the property, and working on projects such as making small products that are sold.

  The center counsels clients on spiritual issues and in cases of relatively minor emotional and mental problems. It does not provide psychiatric help for serious mental illness. Serious cases are referred to licensed professionals for medication or therapy. But care is taken when making recommendations for referral to a non-Amish professional. A local psychiatrist was invited to tour the facility and meet with its Board of Directors. During the meeting, the psychiatrist explained that while biblical counseling was fine, it was insufficient in some cases because “there are some people where their brains just don’t work right … And they have to see a doctor who can treat their brain just like some people have to see a doctor who can treat their heart or kidneys.” The psychiatrist deliberately used the term “brain” rather than “mind,” because it labels the problem as something physical and tangible, for which prescribed medicine might be warranted. The term also helps reduce the stigma that has been associated with “mental” illness. The board thought this explanation made sense and has since used this psychiatrist when help has been needed in serious cases.42