Introduction
Cultural factors are influential in the prevalence, diagnosis and treatment efficacy of mental health conditions (Rathod et al., Reference Rathod, Gega, Degnan, Pikard, Khan, Husain, Munshi and Naeem2018), as culture affects an individual’s life experiences, beliefs and assumptions (Rathod et al., Reference Rathod, Phiri and Naeem2019). The lack of culturally adapted mental health treatments has resulted in low-level engagement and poor outcomes amongst minority cultural groups (Kirmayer, Reference Kirmayer2012). In recent times, cultural competence has become regarded as a crucial skillset for mental health professionals, especially when working with minority cultural groups (Sue et al., Reference Sue, Zane, Nagayama Hall and Berger2009). Over the past two decades, the literature has advanced substantially towards the development of culturally adapted evidence-based interventions for minority cultural groups (Rathod et al., Reference Rathod, Phiri and Naeem2019).
Cognitive behavioural therapy (CBT) has been described as the ‘gold-standard psychological treatment’ for most mental health conditions (David et al., Reference David, Cristea and Hofmann2018; p. 1). While there is a substantial body of research supporting the efficacy of CBT as a clinical treatment (McMain et al., Reference McMain, Newman, Segal and DeRubeis2015), the vast majority of CBT research was conducted by researchers, therapists and clients from Western cultural backgrounds (Beck, Reference Beck2016). Moreover, the principles that underpin CBT are based on Western cultural values which may conflict with the beliefs of some minority cultural groups (Rathod et al., Reference Rathod, Phiri and Naeem2019). Specifically, CBT promotes the Western idea of individual responsibility in the treatment of mental illness, rather than the deterministic philosophical outlook of many non-Western cultures in which life events are viewed to be pre-ordained (Beck, Reference Beck2016; Laungani, Reference Laungani2004). Additionally, CBT is rooted in individualistic Western values which do not emphasise the broader familial, communal and societal factors underlying psychological distress which is central to a non-Western outlook (Beck, Reference Beck2016). Moreover, the empirical approach of CBT attributes the existence of mental illness to the development of unhelpful thought processes and behaviours, which effectively sets aside the social, cultural and religious explanations for psychological distress that are prevalent in some non-Western cultures (Beck, Reference Beck2016). Lastly, CBT advocates for therapists to adopt a collaborative and Socratic therapeutic approach that may be at odds with the non-Western cultural value placed on the social hierarchy in which professionals are expected to be more directive and prescriptive (Guo and Hanley, Reference Guo and Hanley2015). For this reason, it has been argued that the CBT approach requires adaptation to meet the specific needs of minority cultural groups (Nezu and Nezu, Reference Nezu and Nezu2015). This is supported by evidence that culturally adapted CBT for specific minority cultures is more efficacious (Benish et al., Reference Benish, Quintana and Wampold2011; Ng and Wong, Reference Ng and Wong2017). Nevertheless, additional research is required to determine the effectiveness of culturally adapted CBT treatment protocols for various mental health conditions (Rathod et al., Reference Rathod, Gega, Degnan, Pikard, Khan, Husain, Munshi and Naeem2018).
Culturally adapted treatment has been defined as ‘the systematic modification of evidence-based treatment or intervention protocol to consider language, culture and context in such a way that it is compatible with the client’s cultural patterns, meanings and values’ (Bernal et al., Reference Bernal, Jiménez-Chafey and Domenech Rodríguez2009; p. 362). This involves CBT therapists becoming aware of issues pertaining to the family, community, culture, religion and language of minority cultural groups (Rathod et al., Reference Rathod, Phiri and Naeem2019). In this regard, awareness of the philosophical world outlook of clients, especially beliefs around the development of mental health conditions and therapy, is critical to guide the delivery of cultural compatible therapeutic interventions (Naeem et al., Reference Naeem, Phiri, Nasar, Gerada, Munshi, Ayub and Rathod2016). Furthermore, this may uncover cognitive biases and maladaptive beliefs that may contribute to the presenting problem (Rathod et al., Reference Rathod, Phiri and Naeem2019). Lastly, CBT therapists are advised to reflect on their cultural biases and the tendency to stereotype minority cultural groups (Rathod et al., Reference Rathod, Phiri and Naeem2019).
The literature has made several recommendations to culturally adapt the delivery of CBT for minority cultural groups. Firstly, technical CBT terminology should be replaced with culture-specific language, metaphors and stories (Hinton and Patel, Reference Hinton and Patel2017). This can prevent clients from minority cultural groups misunderstanding CBT terms that originate from Western culture (Guo and Hanley, Reference Guo and Hanley2015). Similarly, CBT principles and techniques should be explained using cultural and religious ideas to develop a cultural common ground between client and therapist (Guo and Hanley, Reference Guo and Hanley2015). CBT therapists could consider replacing the collaborative stance and Socratic dialogue with a more directive and prescriptive delivery of CBT for clients from some minority cultural groups, such as Chinese clients. This has been shown to aid the development of a strong therapeutic alliance (Guo and Hanley, Reference Guo and Hanley2015). To reduce the mental health stigma that is prevalent in many minority cultural groups, it is valuable to make clients aware that suffering from mental health conditions is extremely common and highly treatable with evidence-based treatments, including CBT (Hinton and Patel, Reference Hinton and Patel2017). Wherever possible, CBT therapists are advised to frame therapy as an approach to improve psychological functioning and alleviate emotional distress, rather than psychopathologizing symptomology which is likely to increase mental health stigma (Hinton and Patel, Reference Hinton and Patel2017). Lastly, it is recommended that CBT therapists utilise family members and the community as a resource to facilitate therapeutic change for clients from collectivistic cultures (Guo and Hanley, Reference Guo and Hanley2015).
The Orthodox Jewish community
Notwithstanding the burgeoning literature addressing cultural adaptations of CBT for various minority cultural groups, research into CBT and the Orthodox Jewish community is scarce (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996; Rosmarin et al., Reference Rosmarin, Bocanegra, Hoffnung and Appel2019). So much so, researchers have lamented the fact that the Jewish community ‘have mostly been kept on the periphery of the multicultural family’ when it comes to cultural competency in counselling (Schlosser et al., Reference Schlosser, Ali, Ackerman and Dewey2009; p. 62). This is problematic as it has resulted in therapists lacking a culturally compatible evidence-based treatment for this minority cultural group (Schnall et al., Reference Schnall, Kalkstein, Gottesman, Feinberg, Schaeffer and Feinberg2014). Additionally, ‘the lack of attention to Jewish multicultural issues contributes to the Jewish people feeling alienated and marginalized’ (Gehl, Reference Gehl2014; p. 914). Cross-cultural psychotherapy research may have overlooked issues around religious diversity due to the dominant position of Christianity as the majority religion in Western culture (Schlosser et al., Reference Schlosser, Ali, Ackerman and Dewey2009). In addition, there is a wide-spread perception of Jews as a religious group, rather than an ethnic minority (Schlosser et al., Reference Schlosser, Ali, Ackerman and Dewey2009). In actuality, being Jewish will probably affect the cultural, ethnic and religious identity of the individual (Schlosser et al., Reference Schlosser, Ali, Ackerman and Dewey2009). Nevertheless, it is promising that some recent studies have advanced the literature relating to CBT for the Orthodox Jewish community (Kada, Reference Kada2019; Rosmarin et al., Reference Rosmarin, Bocanegra, Hoffnung and Appel2019).
The Jewish community can be divided into several groups, including Orthodox, Reform, Conservative, Liberal and Secular Jews (Kada, Reference Kada2019). Even within the Orthodox Jewish community, there is substantial variation in terms of the language, dress, attitudes towards engagement with secular culture and strictness of religious observance (Milevsky et al., Reference Milevsky, Niman, Raab and Gross2011; Wikler, Reference Wikler1986). This makes it difficult to categorise Orthodox Jewry into distinct homogenous sub-groups (Graham and Vulkan, Reference Graham and Vulkan2008; Schnall, Reference Schnall2006). For this reason, the Orthodox Jewish community is more accurately portrayed as a spectrum of religious observance (Schnall, Reference Schnall2006). This is especially the case since the term ‘ultra-Orthodox’ is considered offensive to many members of the group (Lightman and Shor, Reference Lightman and Shor2002). In this paper, in line with other researchers, we will simply refer to the umbrella group as ‘Orthodox Jews’ (Schnall, Reference Schnall2006). This will encompass several diverse sub-groups that are deeply committed to the practices and beliefs of Orthodox Judaism, including Hareidi, Hasidic and Modern Orthodox Jews (Graham and Vulkan, Reference Graham and Vulkan2008; Holliman and Wagner, Reference Holliman and Wagner2015). This is in contrast to Liberal, Reform, Conservative and Secular Jews who would not identify themselves with this group (Rowland, Reference Rowland2016).
Orthodox Jews are distinguished by their belief that ‘G-d gave the Torah, the Hebrew Bible, to the People of Israel at Mount Sinai, along with a divinely ordained interpretation of its commands’ (Schnall, Reference Schnall2006; p. 277). Orthodox Jews apply the practices of the Torah to all areas of their lives, including daily routines, interpersonal interactions and financial dealings (Milevsky et al., Reference Milevsky, Niman, Raab and Gross2011). For instance, Orthodox Jews will observe kosher dietary laws, attend daily services at synagogue and abstain from forbidden activities on the Sabbath (Rowland, Reference Rowland2016). Orthodox Jews live within close-knit communities and endeavour to be separate from mainstream society to preserve their way of life (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). Orthodox Jewish culture affords considerable value to starting a family and being part of the community (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). Accordingly, Orthodox Jewish communities have been described in the literature as primarily collectivistic societies in which the cultural and religious values and practices of the community have a substantial influence on the lives of individuals (Weiss et al., Reference Weiss, Shor and Hadas-Lidor2013).
Despite the fact that the Orthodox Jewish cultural and religious values and practices will significantly impact the lives of Orthodox Jews (Weiss et al., Reference Weiss, Shor and Hadas-Lidor2013), recent research has highlighted that CBT is an efficacious psychological treatment for various mental health conditions amongst this client group, even without adopting major cultural adaptations during treatment (Rosmarin et al., Reference Rosmarin, Bocanegra, Hoffnung and Appel2019). In addition, CBT has been identified as an ideal treatment to deliver the aims of the Orthodox Jewish community when seeking psychological help for improving psychological functioning and reducing depressive or anxiety symptomology (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). Specifically, while central principles of CBT are considered at odds with some cultural minority groups, they are considered largely compatible with the religious teachings and values of Orthodox Judaism (Shabtai et al., Reference Shabtai, Pirutinsky, Rosmarin, Ives, Ben-Avie, Ives and Loewenthal2016). For instance, the fundamental principle of CBT that an individual’s thoughts and actions influence their mental wellbeing is supported by numerous Orthodox Jewish sources (Shabtai et al., Reference Shabtai, Pirutinsky, Rosmarin, Ives, Ben-Avie, Ives and Loewenthal2016). Furthermore, Orthodox Jewish teachings promote the concept of free-will that human beings consist of positive and negative inclinations and it is the responsibility of individuals to exercise control over their maladaptive thoughts and behaviours (Shabtai et al., Reference Shabtai, Pirutinsky, Rosmarin, Ives, Ben-Avie, Ives and Loewenthal2016). Moreover, Orthodox Judaism views life as a constant process of character self-development and personal growth in which individuals are empowered to adopt a proactive approach to struggle and overcome their personal challenges (Shabtai et al., Reference Shabtai, Pirutinsky, Rosmarin, Ives, Ben-Avie, Ives and Loewenthal2016). However, there is a widespread perception within the community that seeking professional help is effectively conceding that Orthodox Judaism ‘does not have all the answers’ (Strean, Reference Strean1994; p. 39).
Perhaps, the primary barrier preventing individuals seeking psychological treatment is the longstanding mental health stigma within the Orthodox Jewish community (Kada, Reference Kada2019; Schnall, Reference Schnall2006; Schnall et al., Reference Schnall, Kalkstein, Gottesman, Feinberg, Schaeffer and Feinberg2014). However, there is evidence that this stigma has subsided over the past couple of decades, in part due to the campaigns within numerous Orthodox Jewish communities to promote mental health awareness (Prijs, Reference Prijs2019; Schnall et al., Reference Schnall, Kalkstein, Gottesman, Feinberg, Schaeffer and Feinberg2014). Due to the collectivistic nature of the Orthodox Jewish community, societal attitudes and values are highly influential to individuals (Weiss et al., Reference Weiss, Shor and Hadas-Lidor2013). Orthodox Jewish clients are likely to refrain from participating in support groups and informing friends and family members about their mental health challenges (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). In addition, Orthodox Jewish clients are likely to have a heightened interest in client confidentiality (Wikler, Reference Wikler1986). They may fear members of the community finding out that they are receiving psychological support or that their therapist would disclose personal information to their rabbi or community leaders (Holliman and Wagner, Reference Holliman and Wagner2015). The fear of recognition by members of their community can prevent Orthodox Jews from carrying out exposure interventions in public (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996).
Additionally, Orthodox Jews are reluctant to access mental health professionals outside of their community in fear that they will not understand their culture and deliver culturally sensitive treatment (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). Furthermore, Orthodox Jews may fear that their therapist will not approve of their way of life, or even attempt to influence or change their religious beliefs (Haimovich and Leiser, Reference Haimovich and Leiser2017). For this reason, Orthodox Jews are unlikely to access mainstream statutory mental health services (McEvoy et al., Reference McEvoy, Williamson, Kada, Frazer, Dhliwayo and Gask2017). Instead, Orthodox Jews will often choose to work with a therapist who shares their religious beliefs (Schnall, Reference Schnall2006), with the drawback that the client is likely to encounter their therapist at communal events (McEvoy et al., Reference McEvoy, Williamson, Kada, Frazer, Dhliwayo and Gask2017). This is despite the recent finding that Orthodox Jewish clients will achieve the same outcome from CBT delivered by Orthodox and non-Orthodox Jewish clinicians (Rosmarin and Pirutinsky, Reference Rosmarin and Pirutinsky2020).
The research has highlighted that there are benefits in culturally adapted therapy for the Orthodox Jewish community. Therapists can consider the cultural and religious practices of their clients when carrying out the formulation of the presenting problems (Kada, Reference Kada2019). For instance, therapists can enquire about synagogue attendance and religious study to determine psychological functioning (Kada, Reference Kada2019). Furthermore, therapists can adapt CBT techniques and models to factor in the cultural and religious practices of the client (Rosmarin et al., Reference Rosmarin, Bocanegra, Hoffnung and Appel2019). This can include behavioural activation around the Sabbath and religious holidays, and cognitive restructuring around maladaptive religious beliefs, such as mistrust in God (Rosmarin et al., Reference Rosmarin, Pargament, Pirutinsky and Mahoney2010; Rosmarin et al., Reference Rosmarin, Bocanegra, Hoffnung and Appel2019). Similarly, therapists can use religious meditation and meditative prayer as a culturally sensitive intervention to relieve anxiety (Milevsky and Eisenberg, Reference Milevsky and Eisenberg2012). Therapists have been recommended to integrate Jewish parables, metaphors and stories into CBT interventions to convey to Orthodox Jewish clients that CBT is consistent with Orthodox Jewish teachings (Schnall et al., Reference Schnall, Eichenbaum and Abramovitz2016). Furthermore, CBT therapists are encouraged to incorporate religious texts into therapeutic interventions, such as psychoeducation and cognitive restructuring (Milevsky and Eisenberg, Reference Milevsky and Eisenberg2012). Lastly, CBT therapists are advised to collaborate with the client’s rabbi to ensure that their treatment adheres to Jewish law (Kada, Reference Kada2019; Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996; Schnall, Reference Schnall2006). To this end, CBT therapists can present therapy resources to a rabbi for approval before distributing them to Orthodox Jewish clients (Kada, Reference Kada2019).
Although recent publications have advanced the literature relating to cultural adaptations of CBT for the Orthodox Jewish community, this research area remains largely unexplored (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996; Rosmarin et al., Reference Rosmarin, Bocanegra, Hoffnung and Appel2019) and partially outdated (Flasch and Fulton, Reference Flasch and Fulton2019). Importantly, although previous research studies have explored the perspectives of service users, service managers and community leaders (Kada, Reference Kada2019), the literature has yet to examine the experience of therapists towards cultural adaptations of CBT. This is despite the recommendation that qualitative research should consider the experiences and attitudes of mental health professionals in the development of evidence-based guidance to adapt the existing CBT treatment protocols for minority cultural groups (Naeem et al., Reference Naeem, Phiri, Nasar, Gerada, Munshi, Ayub and Rathod2016; Rathod et al., Reference Rathod, Phiri and Naeem2019). Lastly, it is worth noting that the majority of studies relating to culturally adapted CBT with Orthodox Jewish clients consists of case studies outlining the treatment of Orthodox Jews for specific mental health conditions, rather than presenting general guidelines for the cultural adaptation of CBT for this client group (Rosmarin et al., Reference Rosmarin, Bocanegra, Hoffnung and Appel2019). In light of the effectiveness of CBT as a psychological treatment for various mental health conditions amongst Orthodox Jews (Rosmarin et al., Reference Rosmarin, Bocanegra, Hoffnung and Appel2019), it is integral that therapists are provided with evidence-based guidelines to deliver culturally adapted CBT for this client group (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996).
The present study sets out to investigate how CBT therapists culturally adapt therapy for Orthodox Jewish clients. To our knowledge, this is the first research study to explore the perspectives of CBT therapists. It explores the challenges that they encounter when working with this client group and the strategies they have developed to address these challenges. Importantly, this research study adopts a rigorous qualitative methodology, making it one of the first systematic investigations in this research area. It is hoped that this research study will contribute to producing evidence-based recommendations for clinical practice about how to culturally adapt CBT for the Orthodox Jewish community.
Method
Participants
Five CBT therapists working with clients from the Orthodox Jewish community in London took part in the study. Participants all trained at master’s (n = 4) or doctorate level (n = 1) and had at least a postgraduate diploma qualification in CBT, in addition to at least one year of post-qualifying clinical experience working with Orthodox Jewish clients. Participants included both male (n = 3) and female (n = 2) CBT therapists, who ranged in age from 33 to 67 years, and had varying years of clinical experience (1.5 to 26 years). While most participants identified as Orthodox Jews, they came from a diverse range of sub-groups within the Orthodox Jewish community (see Table 1) and one participant was a secular Jew. This sample reflects the presence of varied religious affiliations within the Orthodox Jewish community, as well as the reality in which the majority of Orthodox Jewish clients are referred to Orthodox Jewish clinicians (McEvoy et al., Reference McEvoy, Williamson, Kada, Frazer, Dhliwayo and Gask2017; Schnall, Reference Schnall2006).
Table 1. Participant demographics
Procedure
Face-to-face semi-structured interviews were conducted to allow for verbal and non-verbal communication methods (McIntosh and Morse, Reference McIntosh and Morse2015). The interviews were conducted by C.G., who is male and a member of the Orthodox Jewish community in London. The interviews took place in a private room in the office or home of the participant to ensure their privacy and confidentiality. A semi-structured interview schedule was prepared and adhered to, and the interviewer was able to clarify unclear questions and ask follow-up questions where appropriate. Each interview was held for between 30 and 45 minutes. The interview questions were designed to be open-ended to allow participants to communicate their perspectives and experiences of practising CBT with Orthodox Jewish clients. Following the recommendation of the literature, these questions addressed the experiences of CBT therapists delivering CBT to the Orthodox Jewish community, the challenges they encountered when working with this client group and how they overcome these challenges (Naeem et al., Reference Naeem, Phiri, Nasar, Gerada, Munshi, Ayub and Rathod2016). Other interview questions explored which CBT interventions and techniques were especially helpful with the Orthodox Jewish community and which required adjustment (Naeem et al., Reference Naeem, Phiri, Nasar, Gerada, Munshi, Ayub and Rathod2016).
Data analysis
The interview transcripts were analysed using thematic analysis (Braun and Clarke, Reference Braun and Clarke2006; Nowell et al., Reference Nowell, Norris, White and Moules2017) and an essentialist framework was adopted to delineate the experiences, attitudes and beliefs of individuals (Braun and Clarke, Reference Braun and Clarke2006). This approach can be utilised to develop an insightful interpretation of the data and present a detailed and comprehensive overview of the subject matter (Braun and Clarke, Reference Braun and Clarke2006; Nowell et al., Reference Nowell, Norris, White and Moules2017). To produce meaningful results, thematic analysis has been structured into a methodical approach to data analysis (Nowell et al., Reference Nowell, Norris, White and Moules2017). Firstly, C.G. became familiar with the data by multiple readings of the transcripts (Braun and Clarke, Reference Braun and Clarke2006; Nowell et al., Reference Nowell, Norris, White and Moules2017). As various ideas and concepts began to emerge from the transcripts, these initial themes were recorded and applied to the relevant sections of the data set (Nowell et al., Reference Nowell, Norris, White and Moules2017). After numerous themes were produced for the entire data set, similar themes were assimilated into one another and central themes arising from the transcripts were identified (Nowell et al., Reference Nowell, Norris, White and Moules2017). The themes were then reviewed and categorised into clearly defined master and sub-themes across the dataset (see Table 2) (Nowell et al., Reference Nowell, Norris, White and Moules2017). The data were coded using NVivo which provided an audit trail that was followed and discussed with the second author, M.C.C. (Nowell et al., Reference Nowell, Norris, White and Moules2017).
Table 2. Master themes and sub-themes
It was important that the interviewer, C.G., is a member of the London Orthodox Jewish community. This meant that he was supposedly better placed to understand and interpret the behaviour of this minority cultural group (Hall et al., Reference Hall, Yip and Zárate2016) and that participants would be more comfortable expressing their experiences and attitudes to a researcher who was both a CBT therapist and an Orthodox Jew. Conversely, the authors were aware that this could affect researcher bias and subjectivity. Some actions were taken to minimise any bias and influence throughout the research process.
Firstly, the interview schedule was developed by both authors, C.G. and M.C.C., and consisted of open-ended questions to allow participants to relate their clinical experiences without undue influence. Secondly, the analysis process followed the step-by-step approach recommended for a trustworthy thematic analysis (Lincoln and Guba, Reference Lincoln and Guba1985; Nowell et al., Reference Nowell, Norris, White and Moules2017), with C.G. analysing first and M.C.C. independently checking each phase, from the transcript process to the production of the final report. Meetings were held to discuss and refine emerging themes, and reach a consensus at each stage.
Importantly, throughout the research process, C.G. wrote a reflective memo to monitor his personal biases and interests resulting from his membership of the London Orthodox Jewish community. These reflections were discussed with M.C.C., who is not a member of the Jewish cultural group, as well as with peer therapists who were not involved in the design and conduction of the study.
Results
The thematic analysis of the participants’ responses yielded four themes as well as 12 sub-themes, all of which are summarised in Table 2.
Theme 1: Cultural understanding
One central theme that arose from the data was the importance of therapists being aware of the cultural norms and religious practices of the Orthodox Jewish community. This was perceived to be a key factor in the ability of therapists working with Orthodox Jewish clients.
Role of culture
The consensus of the participants was that culture is an important factor which significantly affects the manifestation of mental health conditions amongst Orthodox Jewish clients. This idea was expressed by one of the participants:
‘The culture is very important and many of the disorders and the problems that we’re dealing with, will be wrapped up in the culture. Someone will be depressed that they won’t be learning or going to the synagogue. Or someone’s anxious, they might be anxious about, you know, keeping certain commandments or what’s going to happen to their children. So, a lot of the problems are going to be connected to the religion and the culture.’ (Participant 5)
These comments highlight the value of therapists exploring cultural and religious issues with Orthodox Jewish clients. Given that the cultural and religious practices of the Orthodox Jewish community apply to all areas of their lives (Milevsky et al., Reference Milevsky, Niman, Raab and Gross2011), it is unsurprising that the observance of these practices is likely to be affected by the onset of mental health conditions.
Nevertheless, all the participants acknowledged that the diagnostic criteria, formulations and treatment plans for the different mental health conditions remain relevant for Orthodox Jewish clients. This perspective was voiced by the participants below:
‘If we’re talking about clinical problems, depression is the same, anxiety is the same, OCD is the same. But the topics would be different, and the content would be different.’ (Participant 1)
‘The models work, the formulations work, but it’s just specific to Orthodox Jewish, I think, problems or vulnerabilities.’ (Participant 2)
From these quotes, it appears that therapists believe that the cultural differences of the Orthodox Jewish community do not justify adopting an entirely different approach to their CBT treatment. This is in line with the recent finding that CBT is an efficacious clinical treatment for Orthodox Jews suffering from anxiety and depression disorders, even without adopting major cultural adaptations throughout treatment (Rosmarin et al., Reference Rosmarin, Bocanegra, Hoffnung and Appel2019). However, Orthodox Jews may often present issues related to their religious or spiritual challenges in therapy (Horowitz and Milevsky, Reference Horowitz and Milevsky2020).
Additionally, several of the participants highlighted the fact that living within the Orthodox Jewish community involves being part of a wider community. This was described below:
‘I think it would be sometimes hard for people not to understand the Jewish world, in terms of the whole social scene, […] living as part of a community, rather than, an independent, individual person. I think that’s quite different.’ (Participant 3)
This comment conveys the importance of therapists understanding the communal dimension of Orthodox Jewish culture. Research has highlighted that Orthodox Jews view themselves as members of a community, and that family and community are central values to this client group (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). For this reason, Orthodox Jewish communities have been described in the literature as primarily collectivistic societies in which the cultural and religious values and practices of the community have a substantial influence on the lives of individuals (Weiss et al., Reference Weiss, Shor and Hadas-Lidor2013). As CBT has been founded on individualistic assumptions, there is a potential risk of focusing solely on the individual without viewing them in their broader context (Dobson and Dobson, Reference Dobson and Dobson2009).
Individual experience
Although therapists believed that it was necessary to explore the cultural background of their Orthodox Jewish clients, they reiterated that the Orthodox Jewish community is far from a homogenous population. This echoes the notion that there is a substantial variation within the Orthodox Jewish community in terms of the strictness of their religious observance and their attitudes towards engagement with secular culture (Milevsky et al., Reference Milevsky, Niman, Raab and Gross2011; Schnall, Reference Schnall2006).
Importantly, several therapists attested to the importance of discerning the specific practices, beliefs and values of each client, as portrayed below:
‘So, it’s always, for me, about understanding what is meaningful to that person and what’s important to them.’ (Participant 1)
This perspective reiterates the notion that the Orthodox Jewish community consists of many individuals, each of whom will have a unique and personal experience. As such, it is integral to ensure that culturally adapted CBT treatment does not result in a one-size-fits-all approach for this diverse client group (Bernal et al., Reference Bernal, Jiménez-Chafey and Domenech Rodríguez2009).
Theme 2: Confronting shame
Another theme derived from the transcripts was the feeling of shame that Orthodox Jews can experience when seeking psychological treatment for a mental health condition.
Combating stigma
There was widespread agreement from participants that the Orthodox Jewish community has made considerable progress to promote mental health within the community, as summarised by the following therapist:
‘I think this community is doing a really good job of promoting mental health, at the moment. You know, talking about it, keeping the conversations coming up and seeing in all of the synagogues, there is always mental health talks.’ (Participant 1)
For some participants, it was believed that mental health campaigns had achieved results in changing the attitudes of the Orthodox Jewish community towards seeking psychological help. This was reflected by the perspective below:
‘My understanding is that it’s breaking down, so people are more comfortable seeking help.’ (Participant 2)
Participants believe that decreasing mental health stigma has contributed to more Orthodox Jews seeking psychological treatment for their mental health conditions, in line with recent research showing that Orthodox Jews are more willing to engage with psychological treatment for mental health conditions (Prijs, Reference Prijs2019; Schnall et al., Reference Schnall, Kalkstein, Gottesman, Feinberg, Schaeffer and Feinberg2014).
Normalising therapy
Even though the mental health stigma has subsided within the Orthodox Jewish community, individuals experienced considerable shame when accessing psychological support.
‘It’s always very difficult for people to make that initial step, yes. It doesn’t feel like people are delighted to, like, “Finally, I’m seeing a therapist” and “Let’s get this sorted”. It’s more like “Unfortunately, I’ve had to come to accept I need a therapist”.’ (Participant 2)
Therapists considered it essential to help their clients manage their feelings of shame when seeking psychological help, as outlined below:
‘I try very much, to sort of, make everyone realise that they’re no different to anyone else. We’re all fallible. We’ve all got our issues and it’s great that they’re dealing with it, but they’re not less than anyone else.’ (Participant 5)
‘I think people feel therapy is this sort of mystical type of process, that people are a bit scared, like “What’s happening here?”. And maybe, just simplifying it, so that people know. And CBT is quite easy for that, so this is what it is, and this is what’s happening.’ (Participant 5)
From these narratives, it is evident that by normalising mental health conditions and outlining the process of CBT, therapists were able to reduce the shame experienced by their Orthodox Jewish clients for seeking psychological support. This finding supports the recommendation that CBT therapists can reduce the mental health stigma of their clients from minority cultural groups by making them aware that suffering from a mental health condition is common and highly treatable (Hinton and Patel, Reference Hinton and Patel2017). Furthermore, Orthodox Jewish clients will benefit from understanding what they can expect from CBT sessions and the common interventions they are likely to encounter during treatment (Holliman and Wagner, Reference Holliman and Wagner2015).
Heightened confidentiality
Several therapists mentioned that Orthodox Jewish clients are particularly secretive about the fact that they have sought psychological help for a mental health condition. This can prevent them from accessing support from their family and friends, as discussed below:
‘There’s a lot of shame. Clients have often told me that nobody apart from their partners know that they’re coming for help, even though, they’re really close to family members and friends.’ (Participant 2)
It has been argued that the secrecy around mental health stems from the close-knit nature of the Orthodox Jewish community in which individuals fear their private information will be divulged (Prijs, Reference Prijs2019). Moreover, Orthodox Jews fear that if community members found out that they sought psychological treatment, it would ruin the marriage prospects of themselves and their families (Prijs, Reference Prijs2019; Weiss et al., Reference Weiss, Shor and Hadas-Lidor2013).
Given the secrecy around mental health issues in the Orthodox Jewish community, it was deemed crucial for therapists to be especially prudent about client confidentiality. Two therapists described how they addressed these issues with clients:
‘In our service, we support that by having a, very, very private entrance and a different exit, so that nobody bumps into each other. That’s how seriously we take it. Also, the management time the appointments so that there are no two people going to be coming in at the same time. It’s a bit of a juggle but that is what we do.’ (Participant 2)
‘In the first session, I always say to people, “The likelihood is that we’re going to bump into each other [in the community]? What do you want me to do if I see you? Should I ignore you? Should I say hello? What should I do?”’ (Participant 3)
This account depicts the great lengths that Orthodox Jewish therapists have gone to, in order to respect the confidentiality of their Orthodox Jewish clients. They may fear community members finding out that they are accessing psychological support or that their therapist would disclose personal information to their rabbi or community leaders (Holliman and Wagner, Reference Holliman and Wagner2015). Therefore, it is helpful to allow clients to communicate their concerns about confidentiality and therapeutic boundaries (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). In response, therapists can inform their clients about their strict adherence to professional guidelines to allay these concerns (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996).
Theme 3: Building trust
A key theme elaborated upon by the participants was the necessity for therapists to elicit the trust of their clients.
Suspicious attitudes
When engaging with a therapist from a different cultural and religious background, Orthodox Jewish clients may fear that their therapist will not approve of their way of life, or even attempt to influence or change their religious beliefs (Haimovich and Leiser, Reference Haimovich and Leiser2017). Consequently, Orthodox Jews may be on the look-out to examine whether their therapist respects their religious values and practices (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). This is expressed by one therapist below:
‘The fear, specifically, in a very close community like the Hasidic community, is the fear of losing their way of life. But once you relax them, that you are not coming to interfere with their way of life, you are, in fact, coming to bring harmony to their way of life, they will go along with you.’ (Participant 4)
Interestingly, this suspicion was also encountered by an Orthodox Jewish therapist working with Orthodox Jewish clients from a different community:
‘The people that I’m seeing who are ultra-Orthodox, ultimately, I’m not them. I’m not exactly from their community. So they’re going to be a little bit suspicious.’ (Participant 5)
This comment highlights that belonging to a different community can evoke mistrust from Orthodox Jewish clients, and even slight discrepancies between the religious practice of the therapist and client can evoke mistrust (Schnall, Reference Schnall2006).
Cultural sensitivity
Given the suspicious attitudes of Orthodox Jews towards mental health professionals, therapists are advised to be sensitive to the cultural and religious needs of this client group. An example of this is provided below by one therapist:
‘So, if it would be a religious man. I would make sure that I was, number one, dressed in a way that was modest. If I felt that eye contact was difficult for him because of a religious, kind of, modest aspect, I would allow more of that space.’ (Participant 1)
Considering ‘modesty’ is an important religious and cultural value for Orthodox Jews, CBT therapists are recommended to dress and interact modestly to facilitate culturally sensitive treatment with this client group (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). So too, therapists should avoid offering a handshake to clients of the opposite gender (Kada, Reference Kada2019).
Even alluding to secular culture would not be culturally appropriate for some Orthodox Jewish clients, as described below:
‘With, let’s say, schoolgirls who are in, kind of, ultra-Orthodox schools where I know they are not allowed to watch TV, or do certain things, I think I would be much more careful to reference TV or songs or things like that.’ (Participant 1)
As Orthodox Jews may be suspicious of ‘outside influences’ interfering with their way of life, culturally competent therapists will refrain from making references to secular culture during therapy (Greenberg and Witztum, Reference Greenberg and Witztum2013; Kada, Reference Kada2019). This effort is crucial to change the perception of mental health professionals as representatives of secular society (Bilu and Witztum, Reference Bilu and Witztum1993).
Furthermore, therapists will refrain from utilising resources or ideas which conflict with the religious beliefs of the Orthodox Jewish community.
‘The only thing I’ve had to adapt or omit various pieces of, is Paul Gilbert’s compassion focused therapy. And that’s because it’s based on evolutionary psychology. And given that I work in an Orthodox Jewish community which believe in a creationist view, I’m sensitive to, you know, work in line of that.’ (Participant 2)
From this quote, it is evident that therapists are careful to ensure that therapy is compatible with Orthodox Jewish religious beliefs. This is in line with the guidance that therapists ensure that therapy appeals to the cultural and religious values of their clients to gain their trust (Rathod et al., Reference Rathod, Phiri and Naeem2019). As self-help materials or worksheets may be viewed with suspicion in the fear that they may contain ‘heretical ideas’, it has been recommended that therapy resources presented to the client are approved by a rabbi beforehand (Kada, Reference Kada2019).
By showing respect for the Orthodox Jewish way of life and displaying cultural sensitivity, it is possible to overcome the mistrust of this community. One therapist provided an example of this from his clinical practice:
‘And the words [the client] said to me, “You saved my life, I will never forget that. And G-d is with you and He will support you”. And I said, “But, I’m not a traditional, kind of person. I don’t follow religion”. [The client] said, “You are a messenger [of G-d] and He will look after you”.’ (Participant 4)
This account demonstrates that a secular therapist can be viewed as a ‘messenger of G-d’, a prestigious title meaning ‘a conduit of G-d’s will’ (Greenberg and Shefler, Reference Greenberg and Shefler2008; p. 190) when they demonstrate genuine respect for Orthodox Jewish religious beliefs and practices. This is compatible with evidence that secular mental health professionals who show respect for the Orthodox Jewish way of life will achieve better clinical outcomes with this client group (Stolovy et al., Reference Stolovy, Levy, Doron and Melamed2013). This echoes the recent finding that Orthodox Jewish clients will benefit equally from CBT delivered by Orthodox and culturally sensitive non-Orthodox Jewish clinicians (Rosmarin and Pirutinsky, Reference Rosmarin and Pirutinsky2020).
Therapeutic relationship
Several participants described the importance of developing a strong therapeutic alliance with Orthodox Jewish clients to gain their trust. This point was stated by several therapists:
‘We are a bit mistrusting, and therefore, they want to feel that this person is not just there to take my money, but he really does care.’ (Participant 5)
‘The Hasidic Jews, unless you make good friends with them in the first few sessions, there is always going to be […] an objection or blockage to have them follow you. And so, they’re not always going to listen to you.’ (Participant 4)
These comments highlight that a robust therapeutic alliance is integral to allay the suspicious attitudes of Orthodox Jewish clients towards therapy. While a strong therapeutic alliance is necessary for all clients in CBT, it is especially important when treating client groups that experience mental health stigma and are suspicious of mental health professionals (Guo and Hanley, Reference Guo and Hanley2015).
Orthodox Jewish therapists found it helpful to build a therapeutic relationship by showing clients with their language that they are unified by their shared cultural background. This was expressed by an Orthodox Jewish therapist:
‘I do it naturally, I don’t really notice that I’m doing it. But I’ll always sprinkle in Jewish texts, a bit of Yiddish, some [religious] learning, so that again, they feel like “Okay this guy, he’s one of us. I can relate to him”.’ (Participant 5)
This illustrates the advantage that Orthodox Jewish therapists have in communicating with Orthodox Jewish clients (McEvoy et al., Reference McEvoy, Williamson, Kada, Frazer, Dhliwayo and Gask2017). As such, a CBT therapist can gain the trust of their Orthodox Jewish clients by demonstrating that they are a member of the Orthodox Jewish community (Horowitz and Milevsky, Reference Horowitz and Milevsky2020). This can be achieved by therapists utilising shared cultural language and exhibiting an understanding of Orthodox Jewish societal norms (Horowitz and Milevsky, Reference Horowitz and Milevsky2020). This can serve to deepen the therapeutic relationship insofar as the client becomes less mistrusting of their therapist and more receptive to CBT principles and techniques (Horowitz and Milevsky, Reference Horowitz and Milevsky2020).
Theme 4: Religious beliefs
The final theme that arose from the transcripts is ‘religious beliefs’, which explores how therapists approach the religious beliefs of their Orthodox Jewish clients.
Religious compatibility
Overwhelmingly, therapists believed that the CBT approach was compatible with Orthodox Jewish beliefs and teachings. This perspective was outlined by several participants:
‘I mean the biggest strength is that there’s nothing in CBT that goes contrary to Judaism and vice versa… Essentially, the actual outlook, basis, foundations that underpin CBT is very much in line with Judaism.’ (Participant 5)
‘I’ve certainly never had any problem with the CBT approach with anyone religious.’ (Participant 3)
These perspectives highlight the fact that therapists deem CBT to be congruent with the religious beliefs and practices of the Orthodox Jewish community. Given the long-standing perceived conflict between religion and psychotherapy for Orthodox Jews (Schnall et al., Reference Schnall, Kalkstein, Gottesman, Feinberg, Schaeffer and Feinberg2014), the finding that CBT fits in with Orthodox Jewish beliefs and practices is noteworthy.
Moreover, some therapists posited that Orthodox Jewish teachings support several of the key CBT principles. This viewpoint is presented by a rabbinically ordained CBT therapist well-versed in Orthodox Jewish religious teachings:
‘When I sit in front of someone who’s an ultra-Orthodox fellow, I don’t need to worry that what I’m going to tell him is going to go against any of his religious outlooks. I don’t need to hide anything, and I can feel very open. And on the contrary, I get actually quite excited, people know that I like to see […] Jewish sources. They will say “What you said last week, I saw it in the Chovos Halevavos [religious self-improvement book]”.’ (Participant 5)
This account portrays the extent to which CBT therapists can be confident when adopting a CBT treatment approach with Orthodox Jewish clients. This is because the Orthodox Jewish religious teachings corroborate several central CBT ideas, including the central CBT model that cognitions and behaviours influence mental wellbeing (Shabtai et al., Reference Shabtai, Pirutinsky, Rosmarin, Ives, Ben-Avie, Ives and Loewenthal2016). This finding is especially significant given the central role of Orthodox Jewish teachings in the lives of Orthodox Jews (Milevsky et al., Reference Milevsky, Niman, Raab and Gross2011). As such, CBT therapists are advised to incorporate religious texts in various therapeutic interventions, such as psychoeducation and cognitive restructuring (Milevsky and Eisenberg, Reference Milevsky and Eisenberg2012).
When there appeared to be a conflict between a CBT principle and a specific religious idea, therapists believed it was essential to explore this collaboratively while maintaining a respect for Orthodox Jewish teachings. This is demonstrated below:
‘Don’t criticise their way of life. Never do. It is their choice. It’s their way of life. So, always say to people, “I appreciate this is what the rabbi said but if you think independently, he probably said this from a good place, but you hear it like a demand on you”.’ (Participant 4)
Therapists were able to work through the perceived contradiction with the client while showing respect for their religious teachings. The research has emphasised the importance of therapists not challenging the religious teachings of Orthodox Jewish clients (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). Instead, it is more helpful for therapists to adopt a pragmatic stance to examine how the two viewpoints could be reconciled, or adopt a flexible and creative treatment approach in which alternative CBT techniques or ideas that are more compatible with Orthodox Jewish religious beliefs are presented (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). By demonstrating cultural sensitivity and accepting Orthodox Jewish teachings, a therapist can engender trust from their Orthodox Jewish clients (Horowitz and Milevsky, Reference Horowitz and Milevsky2020).
Incorporating religious teachings
Several therapists found it beneficial to explain CBT concepts or principles to Orthodox Jewish clients using Jewish teachings. This is demonstrated by the therapists below:
‘Often, when I’m trying to explain to people who need to change their behaviours first, for something like OCD, rather than worrying about their thoughts and their feelings, you have to change behaviours, and then, that comes after. I give them the example of “Naaseh V’nishma” [literally: we will do, and we will listen (the response of the Jewish people when G-d offered them the Torah)].’ (Participant 3)
‘I put to them the difference between a “Mitzvah” [literally: religious commandment] and between a command […]. It is interesting because a mitzvah, it is still flexible. He commanded us to do it, but it’s up to you whether to do it or not. […] But when you say that I have to do it, come rain or shine, that’s anxiety provoking, because you can’t fully guarantee that you do what you’re supposed to do every day. And that seemed to be a switch in many OCD clients because suddenly they’re released from the burden of “I have to do it”, to “I want to do it”.’ (Participant 4)
This underscores how Orthodox Jewish teachings can be utilised by therapists to deliver culturally compatible psychoeducation. Additionally, this strategy can help to allay the fear of Orthodox Jews that seeking psychological help is effectively conceding that ‘Judaism does not have all the answers’ (Strean, Reference Strean1994; p. 39).
Scrupulosity
Orthodox Jews will often present mental health difficulties related to their religious beliefs and practices. For therapists, it was important to make the distinction between normative Orthodox Jewish beliefs and practices, and psychopathological behaviour. This perspective is outlined below:
‘I’m not necessarily seeing people that are ultra, ultra, ultra-Orthodox, it’s rather that part of their observance has become extreme and wrong. And it’s, you know, gone into the area of a disorder.’ (Participant 2)
‘So, the belief is not whether you believe in G-d and Moses and other things, it is whether your beliefs are rigid or flexible. So, we don’t have any issue with the idea that you believe in one G-d or another G-d or anything like this. The only issue we have is if you become literally taken over and everything else does not exist anymore.’ (Participant 4)
These accounts reiterate the crucial finding in the literature that it is not the religious beliefs or practices of Orthodox Jewish clients that contribute towards the development of mental health conditions (Huppert et al., Reference Huppert, Siev and Kushner2007). Instead, it is more likely that due to the nature of the Orthodox Jewish community, mental health conditions will present around issues of religious observance (Huppert et al., Reference Huppert, Siev and Kushner2007). This distinction is fundamental because disputing the legitimacy of a religious practice or belief is exceptionally damaging to the therapeutic alliance with Orthodox Jewish clients (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). As such, it can be helpful for therapists to gain a rigorous understanding of the religious norms within the client’s specific community to determine what behaviours are excessive (Huppert et al., Reference Huppert, Siev and Kushner2007).
Rabbinic guidance
Some therapists highlighted the importance of working collaboratively with a rabbi to deliver therapy that meets the religious needs of the Orthodox Jewish community. This perspective was delineated by a couple of participants:
‘I came to the idea slowly of “Let’s get a rabbi for this. Let’s get a ruling on what should the level of practice, observance, or belief be around this”.’ (Participant 2)
‘And he [the rabbi] was amazingly helpful and supportive, and he said to [the client], “If you ever want to ask me”, because [the client] had tons of halachik [Jewish law] questions, “I’m always here. You can always pick up the ’phone and check it out”. So, that was incredibly valuable.’ (Participant 1)
These quotes shed light on the role of the rabbi as an expert of religious law responsible for deciding religious rulings (Greenberg and Shelfer, Reference Greenberg and Shefler2008). As the authorities on religious law, rabbis can clarify whether specific behaviours fit in with the religious norms of the community (Huppert et al., Reference Huppert, Siev and Kushner2007). Accordingly, it can be helpful for therapists to collaborate with rabbis to identify and challenge any misinterpretations of Jewish law (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). In addition, it can be helpful for therapists to collaborate with a rabbi to ensure that exposure work does not involve performing any behaviour that contravenes Jewish law (Huppert et al., Reference Huppert, Siev and Kushner2007).
Discussion
To our knowledge, this study is the first systematic investigation of the experiences of CBT therapists working with the Orthodox Jewish community. This was conducted with the aim of incorporating the perspectives of mental health professionals in the development of evidence-based guidelines (Naeem et al., Reference Naeem, Phiri, Nasar, Gerada, Munshi, Ayub and Rathod2016; Rathod et al., Reference Rathod, Phiri and Naeem2019).
Clinical implications
There are numerous key findings of this study that have practical clinical implications for CBT therapists. First and foremost is the finding that standardised CBT evidence-based treatment protocols seem to be effective with this client group. This corroborates the recent research that CBT is an efficacious treatment for various mental health conditions amongst Orthodox Jews, even without adopting major cultural adaptations (Rosmarin et al., Reference Rosmarin, Bocanegra, Hoffnung and Appel2019). In fact, this study provides further evidence that the CBT approach is compatible with Orthodox Jewish teachings and values (Shabtai et al., Reference Shabtai, Pirutinsky, Rosmarin, Ives, Ben-Avie, Ives and Loewenthal2016). Accordingly, CBT therapists should consider whether majorly deviating from the evidence-based treatment protocol with this client group is more suggestive of therapist drift than cultural competency (Waller, Reference Waller2009; Waller and Turner, Reference Waller and Turner2016). However, Orthodox Jews may often present issues related to their religious or spiritual challenges in therapy (Horowitz and Milevsky, Reference Horowitz and Milevsky2020).
The results of this study also suggest that CBT therapists working with the Orthodox Jewish community should familiarise themselves with its cultural practices and beliefs. This can enable therapists to adopt a culturally informed approach to treatment in which they enquire about synagogue attendance and religious study to ascertain psychological functioning (Kada, Reference Kada2019). Furthermore, culturally aware CBT therapists can modify CBT techniques and interventions to consider the cultural and religious practices of the client. This can include behavioural activation on the Sabbath and religious holidays, and cognitive restructuring around maladaptive religious beliefs, such as mistrust in God (Rosmarin et al., Reference Rosmarin, Pargament, Pirutinsky and Mahoney2010; Rosmarin et al., Reference Rosmarin, Bocanegra, Hoffnung and Appel2019). This study substantiates the research recommendation that therapists explain CBT concepts utilising Jewish teachings to convey that therapy is consistent with Orthodox Judaism (Milevsky and Eisenberg, Reference Milevsky and Eisenberg2012; Schnall et al., Reference Schnall, Eichenbaum and Abramovitz2016). Nevertheless, these cultural adaptations cannot be at the expense of therapists adopting a curious approach to discover the unique and personal experience of every Orthodox Jewish client. This is especially relevant given the substantial variation within the Orthodox Jewish community (Milevsky et al., Reference Milevsky, Niman, Raab and Gross2011; Schnall, Reference Schnall2006).
Thirdly, this study has brought to the fore that although there is reduced mental health stigma and greater willingness to seek psychological treatment in the Orthodox Jewish community (Prijs, Reference Prijs2019; Schnall et al., Reference Schnall, Kalkstein, Gottesman, Feinberg, Schaeffer and Feinberg2014), CBT therapists continue to perceive feelings of shame from their clients when accessing professional support. With this client population, CBT therapists should endeavour to normalise mental health conditions, explain the process of therapy and attest to the treatability of mental health conditions (Hinton and Patel, Reference Hinton and Patel2017; Holliman and Wagner, Reference Holliman and Wagner2015). Interestingly, the diatheses-stress model appears to be a more culturally appropriate explanation of the development of mental health conditions than the biomedical model for this client group (Pirutinsky et al., Reference Pirutinsky, Rosen, Shapiro Safran and Rosmarin2010). Due to the close-knit nature of the community and the shame of accessing psychological support, Orthodox Jewish clients will probably have a heightened interest in confidentiality (Wikler, Reference Wikler1986). The desire for increased confidentiality should be respected by CBT therapists who should refrain from encouraging clients to become more open about their mental health challenges (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). At the beginning of therapy, it is beneficial to allow clients to communicate their concerns about confidentiality and inform clients about the professional guidelines relating to confidentiality (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996).
Finally, this study highlights the critical role of CBT therapists in gaining the trust of their Orthodox Jewish clients. Orthodox Jews may present with suspicious attitudes towards therapy and therefore be on the lookout for ‘secular influences’ which they consider to be a serious threat to their way of life (Kada, Reference Kada2019; p. 6). To overcome the mistrust of mental health professionals (Bilu and Witztum, Reference Bilu and Witztum1993), it is integral that CBT therapists build a strong therapeutic alliance with their Orthodox Jewish clients (Huppert et al., Reference Huppert, Siev and Kushner2007). This entails exhibiting genuine respect for the Orthodox Jewish way of life and an appreciation that there is no evidence that religious observance causes psychopathology (Huppert et al., Reference Huppert, Siev and Kushner2007; Stolovy et al., Reference Stolovy, Levy, Doron and Melamed2013). To this end, therapists are encouraged to refrain from disputing the legitimacy of religious practices or beliefs and instead target the distorted beliefs surrounding the religious practice or belief responsible for the maintenance of the mental health condition (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). Furthermore, CBT therapists are asked to display sensitivity to the several cultural and religious needs of this client group and ensure that all therapeutic interventions and resources are in accordance with Orthodox Jewish values and beliefs (Paradis et al., Reference Paradis, Friedman, Hatch and Ackerman1996). Our results support the notion that some therapists may find it helpful to collaborate with a rabbi or community leader to clarify the religious norms of the community (Huppert et al., Reference Huppert, Siev and Kushner2007).
Limitations and future research
There are some limitations to this study that are worth discussing. Given the considerable variation of religious observance within the Orthodox Jewish community (Milevsky et al., Reference Milevsky, Niman, Raab and Gross2011; Schnall, Reference Schnall2006), it is questionable to what extent these findings are applicable outside of the London Orthodox Jewish community. As with all cross-cultural psychotherapy literature, readers are advised not to over-generalise these findings or make assumptions about every member of this diverse client group (Schnall, Reference Schnall2006). It may prove beneficial for future research efforts to focus on specific sub-groups within the broader Orthodox Jewish community (Schnall, Reference Schnall2006). A second limitation of this research study was that only the perspectives of CBT therapists were explored. To produce evidence-based guidelines for the cultural adaptation of CBT treatment protocols, qualitative research must study the perspectives of community members, clients and service managers (Naeem et al., Reference Naeem, Phiri, Nasar, Gerada, Munshi, Ayub and Rathod2016; Rathod et al., Reference Rathod, Phiri and Naeem2019).
Conclusions
In summary, this study brings to light the perspectives of CBT therapists towards cultural adaptations for Orthodox Jewish clients. This study has uncovered several key practical implications for clinical practice for CBT with this client group. A key strength of this study was the diverse range of participants, in terms of their professional training, clinical experience and religious affiliation. Further qualitative research is required to gather different perspectives to produce evidence-based guidelines for the cultural adaptations of CBT for the Orthodox Jewish community.
Acknowledgements
The authors would like to thank the five therapists who dedicated their time to share their valuable experiences.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflict of interest
None.
Ethical standards
Authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS. This study was granted ethical approval by Goldsmiths University’s Ethics Committee.
Key practice points
(1) CBT is a culturally appropriate psychological treatment for Orthodox Jewish clients, and it is in accord with Orthodox Jewish teachings and religious beliefs.
(2) There are effective ways of delivering culturally sensitive treatment and working with the religious beliefs and practices of Orthodox Jewish clients.
(3) It is essential to overcome the mistrust of Orthodox Jewish clients towards therapy and mental health professionals.
(4) It is beneficial to address feelings of shame and stigma experienced by Orthodox Jewish clients when accessing psychological support.
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