Shalom Augenbaum Dissertation

The Institute for Clinical Social Work

Psychotherapy from the Perspective of the Orthodox Jewish Patient

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Shalom C. Augenbaum

Chicago, Illinois February 2019

Abstract

Identifying specific factors that make the psychotherapeutic experience helpful is of great importance. Previous studies exploring this task are usually from the perspective of the therapist. This qualitative study, utilizing Interpretive Phenomenological Analysis (IPA) explores the subjective experiences of four Orthodox Jewish psychotherapy patients as a means of identifying the particular beneficial elements of the therapeutic encounter and the dynamics that inhere the Orthodox Jewish patient’s treatment. Eight in-person interviews reveal eight major findings: the integral role of religion; the beneficial role of the therapy milieu and process; stigma and the need to protect the integrity of the Orthodox Jewish patient; the importance of being viewed as a peer-companion; the value of boundary crossings; the value of being culturally matched; therapist training, theoretical orientation and discipline is not a determinant; there is a qualitative difference to how identified factors benefit the Orthodox Jewish patient vis-à -vis non-Orthodox patients. Findings are interpreted using a self psychological perspective and conclusions and recommendations are offered.

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Dedicated to the loving memory of my sister, Chevy Augenbaum, a”h ‫מליא יוכבד בת ר׳ צבי הירש אויגענבוים‬ ‫ה׳ טבת תשנ״ה‬ ‫תנצב״ה‬

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Acknowledgments

This project did not nor could not happen in a vacuum. Indeed, it takes a village to raise a dissertation, and there were many individuals who contributed to its development and path to completion. I therefore gratefully call attention to my exceptional dissertation committee: Denise Duval-Tsioles, PhD, James Lampe, PhD, Connie Goldberg, MS, LCSW, BCD, and Greg Rizzolo, PhD, LCPC. Under any other circumstance or alternate universe, I could not nor would I ask for a more phenomenal committee. And to my chairperson, Karen Bloomberg, PhD. I am grateful not only for her professionalism and vision, but for the wonderful soul that she is. You have my deepest gratitude and blessings.

Lastly, to my professors at ICSW and my wonderful cohort, who, for four years shared their wisdom, ideas, clinical experience and acumen. Much thanks.

SCA 7 Adar I, 5779 Lakewood, New Jersey

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Table of Contents

Abstract..............................................................................................................................ii Acknowledgments.............................................................................................................iv List of Tables......................................................................................................................x Chapter I.

Introduction................................................................................................1 General Statement of Purpose Significance of the Study for Clinical Social Work Statement of the Problem Theoretical and Conceptual Framework Epistemological Foundation of the Study Research Questions Conceptual Definitions of Major Concepts Related to the Study Statement of Assumptions Foregrounding

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Table of Contents—Continued

II.

Literature Review....................................................................................20 Orthodox Judaism – A Historical Context Therapist’s View of the Beneficial Factors of Psychotherapy Patient’s View of the Beneficial Factors of Psychotherapy Orthodox Jewish Patient’s View of the Beneficial Factors of Psychotherapy Chapter Summary

III.

Methodology.............................................................................................86 A Qualitative Approach Rationale for Interpretative Phenomenological Analysis Why Not a Different Qualitative Method?

The Research Sample Data Collection Methods Methods for Data Analysis & Synthesis Ethical Considerations Issues of Trustworthiness Reflexivity – The Role & Background of the Researcher Chapter Summary

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Table of Contents—Continued

IV.

Findings...................................................................................................114 Introduction to Participants Presentation of Findings Member-Checking, Journal Notes, and Researcher Countertransference Chapter Summary

V.

Results.....................................................................................................192 The Double Hermeneutic & Hermeneutic Circle Orthodox Cultural Touchstones Orthodox-Syntonic Treatment Process The Therapeutic Relationship The Therapeutic Factors Chapter Summary

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Table of Contents—Continued

VI.

Conclusions.............................................................................................285 Ultra-Orthodox Jewish Identity and Its Impact on the Therapy Experience Ultra-Orthodox Jewish Identity and the Treatment Process Ultra-Orthodox Jewish Perspective on the Therapeutic Relationship Ultra-Orthodox Jewish Perspective on Helpful Therapeutic Factors Recommendations for the Non-Orthodox or Secular Therapist Recommendations for the Ultra-Orthodox Therapist Recommendations for Schools of Clinical Social Work Recommendations for the Rabbinate Recommendations for Orthodox Jewish Community Activists Recommendations for Orthodox Jewish Persons Seeking Treatment Study Limitations Recommendations for Further Research Personal Reflections Conclusion

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Table of Contents—Continued

Appendices A.

Flyer........................................................................................................303

B.

Pre-Screening Instrument.....................................................................305

C.

In-Person Pre-Interview Script............................................................309

D.

Participant Informed Consent..............................................................313

E.

Interview Schedule.................................................................................318

References...........................................................................................................322

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List of Tables

Table 1. Summary of Findings............................................................................122

x

Chapter I

Introduction General Statement of Purpose The purpose of this phenomenological study was to understand the lived psychotherapy experience from the perspective of the Orthodox Jewish patient.

Specifically, it sought to discover the particular elements of the therapeutic encounter that this population find most helpful, as well as to uncover the subjective attitudes and dynamics that inhere the Orthodox Jewish patient’s treatment experience. In this way, the researcher describes the “lived experience” (Creswell, 1998, p. 65) of the Orthodox Jewish psychotherapy patient within the context of his culture and identity. The study, rooted in the traditions of phenomenology, utilized a phenomenological design and selfpsychological theoretical framework to uncover and better understand these beneficial therapeutic factors. Study participants self-identified as Orthodox Jewish and at the time of the study were engaged in weekly treatment for at least six months. By investigating

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and exploring these phenomena, the study aims to generate hypotheses about the human experience and perception of the psychotherapeutic process from the vantage point of the Orthodox Jewish patient. In so doing, it is hoped that the results of this study can be utilized to enhance the overall psychotherapy experience for the Orthodox Jewish patient and their practitioners.

Significance of the Study for Clinical Social Work Within the field of psychotherapy research, by and large, psychotherapy researchers have tended to pay only scant attention to how the patients’ experience of therapy can contribute to a better understanding of the clinical therapeutic process (Macran, Ross, Shapiro, & Hardy, 1999). This void is compounded when it comes to the Orthodox Jewish community, where “there are no scientifically rigorous studies that examine psychotherapy with Orthodox Jews” (Margolese, 1998, p. 38). And so, undertaking a study that examines the factors of the therapeutic experience that Orthodox Jewish patients find most helpful marks the beginning of a crucial area of research that is necessary to expand the body of knowledge within the field of clinical social work.

Contributing to the knowledge base of the profession, as well as to the provision of culturally sensitive services is in keeping with the social work core value of cultural competence and social diversity (NASW, 1999). Furthermore, therapy can only be effective if accepted by the patient. Absent the knowledge of what the patient experiences

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as beneficial, mental health professionals are hampered in their ability to overcome the unique obstacles that might be specific to Orthodox Jewish culture. By identifying beneficial individual factors, engaging in psychotherapy with the Orthodox Jew can be a stimulating and productive endeavor for both therapist and patient.

Statement of the Problem Although psychotherapy can be a useful and effective treatment for psychological distress (Wampold, 2001; Chorpita, et al., 2011), research suggests that minority groups tend to underutilize mental health services provided by the majority culture, and those who do enter psychotherapy often terminate prematurely (Margolese, 1998). Orthodox Jews are no exception to these statistics. Despite the fact that Jewish beliefs and values extend to all aspects of their life including physical and mental health (Rosner & Tendler, 1997), when it comes to mental health related matters, Orthodox Jews have been reluctant to seek treatment (Schnall E. , 2006). When surveyed, 90% of Orthodox mental health professionals reported that the mental health needs of their community are poorly met (Feinberg & Feinberg, 1985). This, despite the evidence which shows that Orthodox Jews suffer increased rates of severe psychiatric disorders (Bilu & Witztum, 1993). The literature reveals a number of reasons for this reluctance. Among them: 1. The tension between Orthodox Jewish belief and standard therapeutic assumptions creates a great deal of wariness toward psychotherapy and its

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practitioners (Erlanger, 1988). For example, Orthodoxy’s view of homosexuality as ‘an abomination’ (Leviticus, 18:22), is in direct conflict with the perspective of the American Psychiatric Association (Scasta, Bialer, & American Psychiatric Association, 2013). Moreover, psychotherapy appears to have no place for prayer or mitzvos (Godly commandments), no relationship to God, and no essential reason to maintain its connection with the Jewish community (Drob, 1989). The Orthodox Jewish perception of practitioner bias against religiosity is largely based on the fact that psychotherapy was founded on the wisdom of atheist personalities like Sigmund Freud. This wariness of practitioner bias extends to the Orthodox Jewish psychotherapist as well, who Orthodox Jews fear might have been influenced by such wisdom.

2. The Orthodox Jew has a highly developed sense of separateness from the surrounding culture, stemming from an extremely different lifestyle and from the desire to preserve the purity of the religion. This sense of separateness may deepen into mistrust of outsiders. Thus, isolation from neighboring cultures nurtures a somewhat forced intimacy within the community, and in particular within the Orthodox family. This wary attitude toward secular encounters impacts profoundly on the decision to seek treatment in general and the therapeutic relationship in particular, in which Orthodox patients may be mistrustful of the secular therapist’s ability to comprehend their worldview.

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3. The stigma which the close-knit Orthodox Jewish community attaches to those receiving psychological help (Feinberg & Feinberg, 1985) creates a fear that anyone who learns of their situation will consider them ‘crazy’ or ‘insane’ (Wikler, 1986, p. 117). This is compounded by the importance Orthodox Jews place on family background when considering a partner for marriage, which is often wholly or partially arranged after careful investigation (Rockman, 1994). As such, Orthodox Jews often fear that by seeking therapy they are ruining their own, or their families, chances of finding a suitable match (Sublette & Trappier, 2000). As a result, if and when Orthodox Jews present for treatment, they often do so with reluctance, shame and resistance (Feinberg, 2005).

4. Among Orthodox Jews, communication is governed by religious precepts and customs attesting to the deep belief in the power of speech. Particularly relevant to the therapeutic milieu are the following: 1) the commandment to honor one’s parents; 2) lashon ha’ra – the prohibition against gossiping or speaking badly of others; and 3) ayin ha’ra – the fear of bringing evil fortune on oneself by drawing attention to an illness or even human weakness or frailty. Strict adherence to these precepts concerning speech can be detrimental in the therapeutic setting, where, for example, the Orthodox Jewish patient may be reluctant to discuss problematic relationships, especially about parents, whom they are duty-bound to honor. This overriding

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sense of loyalty on the part of the patient may extend to other family members or even the community at large.

One approach that could begin to chip away and diminish this stigma would be to utilize the perspective of the Orthodox Jewish patient to examine the psychotherapeutic process and uncover the specific factors which make their treatments successful.

Increased understanding in this area can help therapists working with this population to form stronger alliances with their patients, and ultimately can improve treatment outcomes. This will allow mental health professionals to feel confident about addressing the challenges of reducing the stigma and shame of mental illness on a public level as well as creating opportunities to educate members of the community regarding the place of mental health within Jewish tradition. Ultimately, the results of this study can serve to shrink the existing stigma surrounding psychotherapy in general and mental health professionals in particular.

Although qualitative investigation suggests that patient perceptions of the therapeutic experience are of great importance to the process of therapy (Macran, Ross, Shapiro, & Hardy, 1999; Hatcher & Barends, 1996), the research utilizing the patient’s perspective is sparse. The literature suggests several reasons which account for the diminished importance ascribed to patients’ viewpoints.

1. From a psychoanalytic perspective, mental disorders occur as a result of the workings of unconscious mental processes, to which the patient ordinarily does not have access. From this viewpoint, individuals can be helped to

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become aware of these processes only with the help of a trained analyst (Freud & Strachey, 1909). A logical consequence of this assumption is that if patients are largely unaware of the processes causing the problems, there is little purpose in asking their opinion about their therapy experience.

2. Patients are simply not skilled enough to make a competent assessment about the therapy they received (Llewelyn, 1988) and are assumed to have a less differentiated view of the therapy process than therapists or experts in the field. Consequently, they may not be aware of how the therapy has been useful (Tyron & Kane, 1993).

3. From a cognitive theory perspective, patients may consciously or unconsciously distort the reported experiences. For example, patients who are depressed, view the world, including the treatment experiences, in a distorted, negative way. And while the aims of therapy are to modify this distorted thinking, from a cognitive viewpoint, asking a patient for his perspective on treatment is worthless because it is distorted and inaccurate (Salkovskis, 1995).

Of the small amount of studies conducted to explore patients’ perspectives, to date only one (Starck, 2008) has dealt with the perspective of the Orthodox Jew. While this study attempted to address the tendency to omit the participants’ ideas on this clinical issue, there continues to be a shortage of qualitative research that has asked Orthodox Jews about their experience in treatment, including what they found useful. Clearly,

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further research is needed in this area. Without this information, not only may we fail to provide what Orthodox Jewish patients need most, but we can also inadvertently reinforce the stigma that currently exists within this community through treatment that is not culturally in line with the Orthodox Jewish perspective.

Given this religious/cultural reality and the obstacle it creates, the following phenomenological study sought to understand and identify the key elements Orthodox Jewish patients find helpful in the psychotherapy encounter. The study utilized qualitative methods to answer the research question. A purposeful sample of adult Orthodox Jewish patients engaged in counseling was utilized with criteria inclusion that participants be 18 years of age or older and actively/previously engaged in either individual or couples counseling. Participation was voluntary and participants were obtained through advertising and brochures. The researcher also asked mental health and medical practitioners within the Orthodox Jewish community to post the brochure in their offices for potential participants to self-select if they choose to be interviewed. Digitally recorded personal interviews and written notes were used as the main sources for data collection.

Theoretical and Conceptual Framework The present study utilized Heinz Kohut’s self psychology as its psychodynamic lens with which to interpret the participants’ experience and data. Because this study was

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interested in the subjective experience of what individuals who had psychotherapy found helpful in their treatments, it is necessary to articulate what is helpful in psychotherapy from a self psychological perspective, specifically, the selfobject and selfobject needs, which are central to Kohutian theory. This is largely because self psychology speaks to the fact that, people learn and grow psychologically when they are faced with positive feelings about both themselves and significant others. It recognizes the impact of the ‘other’ or the selfobject, in nurturing a healthy sense of self through the fulfillment and satisfaction of innate developmental, or selfobject needs, that must be met partially by another person or thing, as the fulfilling of the need is more important than who or what actually fulfills it (Kohut, 1984). Selfobject needs are essential psychological experiences originating in childhood that continue in varying form throughout life. Included in these are the need to idealize, the need to be affirmed, valued and validated, and the need for a sense of commonality and kinship with another human being. These three specific selfobject needs, mirroring, idealizing, and twinship needs are part of the narcissistic configurations Kohut described and focused on (Siegel, 1996).

The development of a healthy self is the outcome of specific tensions within the self-structure. Each of the selfobject needs (tensions) – mirroring, idealizing, and twinship needs – plays an important role in the development of an individual’s nuclear self. According to Kohut, one never grows out of needing and/or having a selfobject milieu; and for Kohut, part of what makes narcissism healthy is based on accepting one’s dependence on, and interdependence with, one’s selfobject milieu and its function in

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building and sustaining a cohesive self-state. Any “normally well-functioning adult will continue to have selfobject needs into adulthood, and therefore developmental manifestations of these should not be looked at as a developmental deficit” (Gilbert & Evans, 2000, p. 66).

Self psychology recognizes that, in therapy, patients come to fix ruptures in their own self experience so as to develop and sustain a healthier sense of self. The therapist makes up the selfobject milieu of the psychotherapy treatment and contributes towards the development of the patient’s self (Rowe & MacIsaac, 2004). Consequently, a critical aspect of the selfobject milieu is the patient’s experience of the therapist in the room and the adequacy of the milieu in meeting the developmental needs during psychotherapy will be decisive in determining the fate of the patients emerging self (Gardner, 1991). It is assumed that patients have their own unmet selfobject needs and in an attempt to heal self-deficits, they will naturally form mirroring and idealizing transferences. An important aspect of treatment is for the therapist to identify these selfobject transferences within the therapy process as they develop. Mirroring needs may be expressed as the wish for validation from the therapist, or the “gleam” in the therapist’s eye. Idealizing needs may be expressed when the patient admires the therapist and looks to the therapist to gain a sense of strength, emotion regulation, or protection. Feeling similar to or connected to the therapist may satisfy twinship needs. These positive self-feelings contribute to increased cohesion and a stronger intrapsyche in the patient, which facilitates the development and strengthening of the self during this time in treatment

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(Teicholz, 1998). In addition, it is critical for the therapist to be aware of the injuries that ensue when they are not met (Kohut, 1977).

Self psychology is thus an effective model for this study, in that clearly the therapy experience includes the therapist who serves multiple selfobject functions which in turn influences the relationship and contributes to the patient’s self-state. According to Stolorow, Atwood, and Orange (1999, p. 383) it is the “felt responsiveness” of others that co-determines the organization of self-experience. This study paid particular attention to the selfobject relatedness within the therapist-patient matrix, and how it manifested and positively impacted the patient’s subjective experience in treatment.

Furthermore, based on the Orthodox Jewish community’s negative perception of psychotherapy in general and its practitioners and attendees in particular, the Orthodox Jewish patient might be filled with shame-infused feelings as he begins to engage in the therapy process. Self psychology acknowledges the concepts of shame and narcissism and considers them interconnected and inseparable. Described as the “affect at the very core of a derailed narcissistic experience” (Morrison & Stolorow, 1997, p. 65) shame refers to a painful feeling about one’s self in relation to one’s whole self. Narcissistic injury, defined as “the damage experienced by an individual’s real self,” (Halewood & Tribe, 2003, p. 88) is the response to feeling ignored or hurt by an unresponsive, misattuned, or otherwise under-stimulating selfobject milieu (Morrison, 1994). Therefore, to best understand how Orthodox Jewish identity might impact the subjective experience

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of the psychotherapy patient and his perception about the beneficial aspects of treatment, self psychology with its understanding of the impact of shame on the self, was chosen.

Epistemological Foundation of the Study According to Hartley (2006) epistemology is the process through which the researcher makes the knowledge claim. While the natural sciences utilize positivist methods to study phenomena, for the human sciences such an approach is inappropriate.

Rather, the research design and the methodology are shaped and influenced by a philosophical worldview (Creswell, 2014). As such, this study, which sought to better understand the subjective experience of patients in treatment, utilized a hermeneutic phenomenological perspective, that is, an interpretive discipline dealing with meanings (Laverty, 2003). Based on the writings of Heidegger, hermeneutic phenomenology is rested on the ground of the subjective experience of individuals and attempts to unveil their world through interpretive narration of their life experiences. This school believes that interpretations are all we have and that indeed, description itself is an interpretive process. For the study at hand, the object that we wish to understand and interpret is the Orthodox Jewish patients’ previously unarticulated experience of the psychotherapeutic relationship. The phenomena this project sought to elucidate is therefore consistent with hermeneutic phenomenological philosophy, in that knowledge-making is possible through subjective experience and insights which we study and interpret.

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Research Questions This study addressed the question: What is the lived psychotherapy experience from the perspective of the Orthodox Jewish patient? Related questions include: 1. What are the specific beneficial elements of the therapeutic encounter as experienced by Orthodox Jewish patients?

2. What about the therapy process feels helpful to Orthodox Jewish patients?

3. How did one’s Orthodox Jewish identity impact his or her subjective experience of psychotherapy?

4. How do Orthodox Jewish patients’ experiences of treatment compare with existing definitions in the current literature?

The overall objective of this study was to gain a deeper understanding of the patient’s experience of the therapeutic experience, with specific, individual factors being identified as most helpful.

Conceptual Definitions of Major Concepts Related to the Study As a means of better comprehending the population this study comprises, a brief definition of Orthodox Judaism is in order. A more detailed background will be provided in the following chapter.

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Judaism: Judaism is a practice-oriented religion, characterized by numerous rituals and laws that permeate nearly every area of existence. Jewish law, or halachah, is a detailed legal code that is based on rabbinic interpretation of the Torah [written law] and Talmud [oral law] and establishes its application in daily life. Customs relating to precise practice differ even within the Orthodox community, and it is expected that community members have specific rabbis on whom they rely for legal and spiritual guidance. Especially in Ultra-Orthodox Judaism, (a more theologically strict and traditional version of Orthodox Judaism), rabbinic authority supersedes individual autonomy.

Orthodox: The term ‘orthodox’ is defined from the Greek as “correct thought” and is more commonly understood as “conforming to established doctrine especially in religion” (Merriam-Webster, 2003). As it applies to Judaism, ‘Orthodox Jewish’ signifies individuals who generally believe in the divinity of the Written Law (Torah) and Oral Law (Talmud) and who, at minimum, practice the core observances of the 613 mitzvos (commandments) that define Orthodox observance (Strean, 1994). These are Shabbos (observance of the Sabbath, the holy day of rest), kashrus (dietary laws), and niddah (laws of family purity). Due to the nature of Orthodox laws, such as prohibitions against driving on Shabbos, the need to obtain kosher food, and the laws of family purity, Orthodox Jews tend to reside in socially and geographically close-knit communities.

Within Orthodox Judaism, there exists a range of individual practice variation. For example, even within a community, individuals may have different practices regarding

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the allowance of being alone with a nonfamily member of the opposite sex (known as yichud). Some may refuse, while others may allow for it if the door is slightly open or closed but not locked, the nuances of which will not be discussed here.

Many researchers have noted that the Orthodox Jewish community is developing greater awareness of mental health needs and is showing an increased readiness to receive appropriate care (Lightman & Shor, 2002; Sorotzkin, 1998). This readiness coincides with a burgeoning of mental health lay literature written by Orthodox Jews, often intended specifically for the Orthodox community (Adahan, 1994; Boteach, 2000; Twerski, 2004). It is worth noting, however, that community members do not seek help exclusively from Orthodox Jewish clinicians. Rabbi Moshe Feinstein, a leading 20th century authority on Jewish law, ruled that under proper circumstances, religious guidelines permit obtaining mental health care from clinicians outside the community (Wikler, 1989). In sum, research on mental health issues that have an impact on Orthodox Jews is relevant to professionals both within and outside the community who wish to offer culturally competent counseling to its members.

There are various streams and sects of Orthodox Jews that are distinguished by differences in custom and dress, with community members strongly adhering to their unique traditions and ideologies. Examples of these include but are not limited to: UltraOrthodox, Yeshivish Modern, Modern Orthodox, Modern Orthodox Machmir [stringent], and Modern Orthodox Liberal. Two of these categories will be defined here as these are most relevant to this study. It is important to state that the general term “Orthodox Jew�

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is often interchanged with “Ultra-Orthodox” because many within the Jewish community find labeling/categorizing as offensive and insulting (Lightman & Shor, 2002). In this vein, this study will use both terms interchangeably as well.

Ultra-Orthodox: sometimes known as ‘Yeshivish Black Hat’. For individuals that comprise this camp, Torah learning, prayer, and careful adherence to fulfillment of mitzvos [commandments] are core elements to a life of intensive religious commitment and spiritual growth. Strict and unbending loyalty to halachah [Jewish law] is seen as normative. Limiting exposure to the secular world is encouraged, and barriers or gedarim [literally: fences] are seen as essential to protecting against secular influences. UltraOrthodox Jews place great importance on the position of rabbis not only as spiritual leaders of the community, but as sources of personal guidance as well. It is common even for someone quite learned to ask a rabbi questions that an outside observer might imagine could be answered for oneself. The distinctive worldview of the Ultra-Orthodox, with its assumption that Judaism will flourish only if Jews sequester themselves in selfsegregating enclaves, illustrates the many challenges the mental health field faces when dealing with this community in general and serves to highlight their resistance against attending treatment in particular.

Modern Orthodox: individuals who are Shabbos and kosher observant and maintain their lifestyle according to the main rules and guidelines of halachah, though sometimes with greater leniencies than the Ultra-Orthodox. These individuals may or may not be involved in regular and consistent Torah learning or prayer. They are modern

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in the sense that they are not Yeshivish and readily engage in the secular world while leading an Orthodox observant life.

Statement of Assumptions An underlying assumption from which this study ensued is that psychotherapy is, indeed, helpful. Secondly, because this study employed a self psychological conceptual framework to interpret the data, it further assumed that the self-selfobject milieu, or the external relations between the self and objects, is a key factor in the success and helpfulness of psychotherapy and as fundamental to the patient’s human experience/psychological life. This research project therefore paid specific attention to the individual factors of the patient-therapist relationship such as the needs for affirmation, admiration, and connection with others. Thirdly, it was assumed that a participant’s identification as Orthodox Jewish would be a salient factor in potentially shaping each individual’s perception of the beneficial aspects of therapeutic action, in addition to impacting the kind of relationship a participant established with the therapist.

Lastly, as echoed by Krohn (2016) , this study assumed there is no “single therapeutic element” to therapeutic action. Rather, several pathways exist to explain the beneficial effects of therapy which depend upon multiple interacting processes, including factors that are unique to the patient, the therapist, or the third space (Ogden, 1989) created and shared by the dyad.

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Foregrounding As an Orthodox Jewish psychotherapist working within the Orthodox Jewish community, I am privy firsthand to the multitude of issues and challenges the Orthodox Jewish community faces. These include but are certainly not limited to issues such as trauma, abuse, addiction, depression/anxiety and relationships. Numerous men and women from the Orthodox Jewish community have approached me at family and social events sharing their struggles and challenges, and I immediately inquire as to whether they have sought out the services of a licensed psychotherapist. To my chagrin the responses usually range from the belief that therapy would not be of assistance, to the fear that psychotherapy may neglect the value and importance of religion. Others who might have attended treatment, speak shamefully of their therapy as some form of a necessary evil. In addition to the lack of research, these perceptions compromise the efficacy of those mental health professionals who treat Orthodox Jews and contributes to the ongoing reticence of Orthodox Jews seeking treatment. This is frustrating and disappointing because as a practitioner and as one who has attended his own psychotherapy treatment, I know and believe that psychotherapy holds the promise of helping people overcome their struggles and challenges. To properly do so, it is imperative to pay attention to what our patients find most helpful, particularly the Orthodox Jewish patient. It is hoped that this study will be a first step in overcoming the above-cited barriers with its findings and recommendations for clinical practice and

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further research with this population. In this way, the results of this project will increase the readiness of Orthodox Jews to accept help from the mental health profession and will assist those who treat them in meeting those needs.

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Chapter II Literature Review The review of related literature begins with a brief description about important aspects of Orthodox Jewish culture that include the epistemological tools associated with, and sources of knowledge accepted by, this population. After placing the Orthodox Jewish religion within a historical context, the discussion moves to this culture’s relationship with Freud and psychoanalysis and how this relationship influenced the Orthodox Jewish attitude toward psychotherapy and its practitioners. From there, the researcher explores therapeutic action from the viewpoint of the therapist, examining three broad models discussed in the literature and what is considered helpful or curative in treatment. The discussion then continues on to the literature concerning the patients’ viewpoint about therapeutic beneficial factors. Last, the discussion looks at Orthodox Jewish adult patients’ perspectives on their therapy and what they reported as having been helpful in treatment, a topic that has not been heavily discussed within the research in general.

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Orthodox Judaism – A Historical Context While much attention has been paid to visible minorities; not much attention has been paid to invisible minorities, or groups whose status as a minority is based on a characteristic that is not always apparent (Schnall E. , 2006). Examples of invisible minorities include those identifying with the lesbian, gay, bisexual, transgender, queer community (Priola, Lasio, De Simone, & Serri, 2014), persons previously incarcerated in correctional facilities (Ross, Jones, Lenza, & Richards, 2016), persons struggling with poverty, and many more (Schlosser, 2006). With the notion of invisible minorities, the Orthodox Jewish community is considered invisible in many contexts including the counseling profession. This invisible nature of the Jewish community has resulted in a relative dearth of professional literature providing cultural context and treatment guidelines for psychotherapists serving this population (Altman, Inman, Fine, Ritter, & Howard, 2010) as well as what the Orthodox Jewish patient might feel is most beneficial about the psychotherapy encounter, the subject of this study. This is troubling considering the significant number of Jewish people in the world and in the United States. As of 2017, the Jewish population around the world was estimated at 14,412,200, which is 0.70% higher than the 2014 estimate (DellaPergola, 2017).

Judaism is among the world’s oldest monotheistic religion and the fundamental belief in one transcendent God as the source of creation is central (Corrigan, Denny,

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Jaffee, & Eire, 2016). One of the cornerstones of Judaism is to “love your neighbor as yourself� (Leviticus 19:18), and demands of the Jew to be ethical, selfless, and othercentered. Based on this ethical teaching, charitable and support organizations can be found in Jewish communities around the globe and are characterized by their dedication and commitment to carrying out communal good works (Plant & Weiss, 2015).

Under the general term Judaism lay many subgroups, one of which is Orthodox Judaism. This subgroup of Jews believe that God revealed via Moshe [Moses] important teachings to humanity, which were passed down and expanded upon by generations of pious scholars (Ethics of the Fathers, 1:1). Orthodox Jews in general accept and practice certain laws and customs and while there are slight differences among the varying subgroups of Orthodox Jewry, by and large for Orthodox Jews, religion is the primary modus operandi of life itself, and they are unified by their adherence to kashrus [dietary laws], Shabbos and Yomim Tovim [Sabbath and festivals], the sanctity of marriage [strict monogamy], encouragement of regular prayer and religious study, and place a high value upon the Jewish home and family as the center of religious life (Loewenthal, 2006).

Emphasis is placed upon the chinuch [education] of children, who are regarded as blessings of which one cannot have too much. As a result, families tend to be large, and it is not uncommon to have six to ten children per family (Schnitzer, Longman, Loots, & Valdebenito, 2011). This is in stark contrast with non-Orthodox Jewish families, who average fewer than two children per household (Holman & Holman, 2002).

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Another important feature of the Orthodox Jewish community relates to their manner of dress. For insiders within the Orthodox community, an individual’s mode of dress sends important signals about religious identity and group membership which include subtle but very real distinctions in customs, allegiances, and ways of living.

While it is impossible to fully capture all of the diversity within Orthodox Judaism, the Orthodox can be broadly divided into two categories: The Ultra-Orthodox and the Modern-Orthodox.

Ultra-Orthodox Jews.

Jews who fall under the Ultra-Orthodox group are called charedim, [literally: those who tremble or fear God] and can be distinguished by their strict mode of dress (Heilman, 2017; Schlesinger, 2014). Men usually don conservative dark clothes, wear black skull-caps [yarmulkes] and black hats and usually grow beards (Silverman, 2013).

The women adhere to the laws of tzinus [modesty] which requires modest outfits that cover the knees, elbows, high necklines, and for married women the covering of hair (Silverman, 2013). There are varying groups within charedi circles, of which the most noticeable are Chasidim [literally: pious ones]. The Chasidim, who are divided into at least two dozen sects, encourage religious enthusiasm and mystical experiences. They are also more likely to cluster around a charismatic leader, a Rebbe, whom they view as their liaison to God. A second faction within the charedi group are the Yeshivish [literally:

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those who sit – referring to those who sit and study Torah], who are stringent in their religious practice and whose lives are oriented around upper-level academies of Torah study (Heilman, 2017; Schlesinger, 2014). In contrast to the Chassidim, who are guided by a singular leader, members of the Yeshivish community are typically affiliated to a Yeshiva [a center of Torah scholarship] or a particular synagogue. For this subgroup, Torah scholarship is seen as the ultimate in achieving connection and servitude to God. Within the Ultra-Orthodox circles, it is commonplace for young people in their late teens or early twenties to start dating for marriage purposes (Valins, 2003). The dating process is facilitated either by parents or professional matchmakers and, once married, the young couple is expected to produce children. Charedim living the United States generally perceive culture to be a direct threat to Orthodoxy, but will still enter into secular professions, if necessary. Despite this, they will do everything to avoid being influenced in their personal lives by secular practices or norms (Waxman, 2017). They prefer to live in insular wholly Ultra-Orthodox communities, far removed from the centers of American Jewish life where they can “do their own thing� and not have to interact with secularists (Bilu & Witztum, 1993). Some of the primary geographic locations in which Chasidic and Yeshivish families reside include Lakewood, New Jersey, and Borough Park, Flatbush, Crown Heights, Williamsburg, and Monsey, New York.

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Modern-Orthodox Jews.

Jews in this group are called daatim [literally: religious] and are not as insular and tight-knit as their more observant counterparts. Men usually don more casual attires than their Ultra-Orthodox peers but may wear colored or crocheted skull-caps (Waxman, 2017). The dress of women, while modest, may not completely follow the strict dress code of the Ultra-Orthodox. Although the Modern-Orthodox obey all of the religious commands regarding observance, family life, and prayer, they may mingle in educational and work settings with their non-Jewish or less observant peers. The Ultra-Orthodox may comprise about 10% of world Jewry, though estimates are hard to obtain. Estimates of the numbers of Modern-Orthodox are even harder to make, but perhaps about one-third to one-half might identify themselves as Modern-Orthodox.

Education.

In contrast to the Modern-Orthodox, secular study among the Ultra-Orthodox Jews is not highly regarded and may be seen as antithetical to Jewish values. For UltraOrthodox men, particularly those within yeshivish circles, striving towards a career in religious studies and teaching is held in esteem and most rewarding. The intellectual demands are high, and the focus of study is Jewish law and tradition, with no significant attention being given to wider cultural, literary, artistic or scientific topics (Finkelman, 2011). Although, college education among the men is rare, some undergo technical

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training which enables them to enter the computer or small business industry as a source of livelihood (Gonen, 2001). Over the past decade however, several culturally-sensitive programs have been created which allow Ultra-Orthodox Jewish men and women access to higher education without having to compromise their religious values and observance, and this researcher is a product of one such graduate (MSW) program.

Women within Ultra-Orthodox circles tend to have a broader education than the men and may choose to go to college and university. Nevertheless, women will prioritize marriage and family commitments and as mentioned, there is likely to be a heavy value on having as many children as possible. Ultra-Orthodox women will commonly contribute towards the improvement of family livelihood, and within the yeshivish circles, are generally the main breadwinners so their husbands may engage in religious studies uninterrupted (Loewenthal, 2006). In contrast, the Modern-Orthodox embrace secular study, and medicine, law, and business are considered popular careers. Similar to the Ultra-Orthodox, Modern-Orthodox women are free to prioritize family care if they wish, but they tend to have active, earning professions (Baum, Yedidya, Schwartz, & Aran, 2014).

The Ultra-Orthodox strive to be self-sufficient in as many as aspects as realistically possible. This is a culture that thrives on mutual aid and charity, as evidenced by the thousands of small aid organizations that offer all kinds of assistance (Spitzer, 2003). To support self-sufficiency and to avoid unnecessary interface with the secularists, the Ultra-Orthodox use knowledge ‘imported’ from the outside in the form of baalei

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teshuvah [repentant or returnees to Judaism] who have joined the Ultra-Orthodox camp, or from those Ultra-Orthodox Jews who pursued higher education (Pirutinsky, 2009).

While the Ultra-Orthodox strive for functional independence from the secularists, realistically they are not autonomous enough to separate entirely. This has specific relevance for the Orthodox Jewish patient seeking medical and mental health services, to which our discussion now turns.

Medical services among the Ultra-Orthodox.

With regard health and illness, the Torah and its derivative commentaries contain important values (Dorff, 1998). According to Orthodox Jewish philosophy, God is the creator of a purposeful and orderly universe, and the earth full of God’s creatures, including humans, belong to God. Humans are mandated to engage in life preservation, to secure their safety and avoid dangers, and to never willfully destroy their bodies.

Consequently, Judaism strongly emphasizes preservation of life, loving others, protection against self-harm and a physician’s duty to heal (Kinzbrunner, 2004).

Historically however, most classical rabbinic sources are ambivalent towards doctors and medicine (Preuss, 1978). The essential contrast between faith in God as Healer (Exodus 15:26) and the need to turn to a mortal physician whose authority stems from professional skill and not religious observance or belief, creates an unavoidable tension. This tension, aggravated by cases of treatment failures, led to the many negative

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Talmudic and rabbinic attitudes toward medicine. Hence the Talmudic adage, “The best of doctors goes to hell” (Babylonian Talmud Kiddushin 82a).

Nevertheless, medical issues (some of it favorable) occupy a great deal of space in the Talmud and throughout Jewish literature (Rashi, Exodus 21:18-19), and rabbinic leaders routinely referred those suffering to medical practitioners. Furthermore, the long tradition of great physicians throughout Jewish history, who were also great rabbis (the most famous being Rabbi Moshe ben Maimon – Maimonides), would appear to firmly establish the Torah’s positive attitude towards medicine and physicians. Eventually, this tension between faith in Divine healing versus seeking a physician’s help was resolved by various Talmudic statements such as “doctors are messengers of God” or “instruments of God” (Bilu & Witztum, 1993). This seems to be the conclusion of The Code of Jewish Law [Shulchan Aruch] as well, which states that the main qualification to look for when choosing a teacher is that the individual be a God-fearing Jew. In contrast, when seeking a medical practitioner, one is obligated to seek the most professionally competent, regardless of religiosity (Ganzfried, 1850). In contemporary times, almost all Orthodox authorities support the obligation to seek medical treatment and the understanding that medical practitioners are empowered by God to heal.

Mental health services among the Ultra-Orthodox.

In addition to medical services, mental health care is another area where the UltraOrthodox find themselves uncertain and hesitant about how to define treatment.

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Regarding psychotherapy and counseling, the guidance of the Code of Jewish Law appears vague – is one receiving “teaching”, or “medical assistance?” And so, nowhere is the ambivalence towards practitioners more acute than in the field of mental health. In practice, the more strictly Orthodox and their rabbis view mainstream psychotherapy and counseling services negatively. Consequently, for the Ultra-Orthodox individual, seeking psychotherapeutic services is considered as a last resort after most other options including rabbinic figures, kabbalists, general family doctors or neurologists fail to alleviate suffering. These latter referrals imply attempts to attribute physiological causation for emotional problems. Historically however, references of emotional well-being, psychopathology and seeking treatment can be found throughout many of the traditional Jewish sources (Loewenthal, 1995). In the following section, the review will consider mental health within this historical setting.

Historical perspective of mental illness.

The Bible details the story about the ancient Hebrews wandering through the desert with Moses, and their impatience and despondency over his delayed return with the Ten Commandments, leading to the construction of the Golden Calf (Exodus 32).

Although Moses shattered the first set of the Ten Commandments, these original broken tablets were carried along with, and later placed in the Holy Ark together with, the new whole ones. Symbolically, the preservation of the broken tablets represents God’s love and acceptance of humanity, no matter how shattered and broken. It is also instructive

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about the obligation to include all parts and members of society, specifically the downtrodden and suffering. Jews are therefore expected to assist, guide and provide support to those who are struggling (Dorff, 1998). Indeed, Jews enter the disciplines of psychiatry, psychology, social work, and the helping professions, driven by the aforementioned mandate to assist the disenfranchised.

The idea of seeking treatment for one’s challenges is hinted at in the Talmud which states that “a person cannot heal himself, because a prisoner cannot free himself from prison” (Babylonian Talmud Berachos 56). In this vein, Maimonides urged the mentally ill to avail themselves to a “physician of the mind” (Code 1:2). In his Guide to the Perplexed, Maimonides states that prevention is important and stresses the importance of balance for the spirit through self-discipline and mental calm which aid the soul (Spero, 1980).

Furthermore, the Bible is replete with references to contemporary mental health issues including epilepsy, phobias, and melancholy (Encyclopedia Judaica, 1971). For example, Deuteronomy (28:28) identifies “madness” as a punishment for disobedience.

The Book of Genesis records the emotion of depression when referencing the story of Cain and Abel and is the first depressive episode mentioned in Scripture. Additionally, in the Book of Kings, King Saul demonstrated what would be diagnosed as suicidal depression and homicidal paranoia and was quite possibly the first person treated with music therapy, administered by David on his harp.

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Traditionally, mental illness was not considered a moral defect, and the goal was to disenfranchise the person as little as possible (Spero, 1980). From a legal standpoint, the Talmud characterizes mental illness as ‘shtus’ [(mentally incompetent) and the inability to reason or make reality-based judgments. The Talmud (Babylonian Talmud Chagigah 3b-4a) asks and answers: “who is deemed insane? He who goes out alone at night, who sleeps in the cemetery, tears his clothes, and destroys everything given to him.”

And so, as the literature clearly indicates, from the earliest periods of time, mental illness and the importance of treatment were dealt with in Judaic writings, law, and philosophy. Nevertheless, since Freud introduced the theories and ideas which form the basis psychoanalysis, Ultra-Orthodox Jews have viewed psychotherapy with suspicion, disdain and in some cases, outright contempt (Schnall, et al., 2014). In the following sections, we explore the literature which maps out the historical context and reasons for this distancing and resistance. We begin by exploring the general cultures reaction to Freud and his revolutionary ideas during that period.

Psychoanalysis and general culture.

In the period prior to 1933, the perception among many anti-Semites within the general society, was that Jewish intellectuals were undermining German culture (MacDonald, 1998). Psychoanalysis was not immune to this hostility, which stemmed from its perceived threat to Christian sexual ethics including the tolerance of

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masturbation and premarital sex (Kurzweil, 1989, p. 18). Freud’s work became a target decrying the Jewish subversion of culture, or the “decadent influence of Judaism,” (Klein D. B., 1981, p. 144). According to Gay,

While the implications of Darwin’s views were threatening and unsettling, they were not quite so directly abrasive, not quite so unrespectable, as Freud’s views on infantile sexuality, the ubiquity of perversions, and the dynamic power of unconscious urges” (1987, p. 144).

In 1928, Freud’s book “The Future of an Illusion,” which analyzed religious belief in terms of infantile needs, came under harsh criticism from Carl Christian Clemen, a professor of ethnology at the University of Bonn. Decrying the psychoanalytic tendency to overemphasize sex, Clemens attributed this to the movements Jewish composition, stating: “One could explain this by the particular circles from which its advocates and perhaps, too, the patients it treats, principally hail” (Gay, 1988, p. 537). Eventually, Freud’s books were burned in the May 1933 book burnings in Germany, and when the Nazis entered Vienna in 1938, they ordered Freud to leave and abolished the Internationaler Psychoanalytischer Verlag.

Freud’s attitude toward religious belief can be characterized as decidedly negative. He presumed all religious belief to be of a neurotic nature, most closely linked with obsessional character defenses. In the Future of an Illusion, Freud asserts that the purpose of religion is for “defending oneself against the crushingly superior force of

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nature” (1927, p. 21). In Civilization and Its Discontents, Freud states “the origin of the religious attitude can be traced back in clear outlines as far as the feeling of infantile helplessness” (1930, p. 72). Paul Ricoeur remarked: “One only has to read The Future of an Illusion, Civilization and its Discontents, and Moses and Monotheism to be convinced that Freud is one of the outstanding atheists of contemporary culture.” (1966, p. 52).

Despite Freud’s rejection of religion and the great pains he took to conceal his identity from others, it appears he had a strong affinity with his Jewish identity. In a 1931 letter, he described himself as “a fanatical Jew,” and on another occasion, wrote that he found “the attraction of Judaism and of Jews irresistible” (Gay, 1988, p. 601). By the 1930s Freud also became strongly sympathetic with Zionism. And so, whereas his private correspondence is filled with a strong sense of Jewish ethnic identity, his public statements and writings exhibited a “generally guarded, distanced tone” (Yerushalmi, 1991, p. 42).

Psychoanalysis and Orthodox Judaism.

From the side of Orthodox Judaism as well, the relationship with psychoanalysis has been dominated by writers who see psychoanalysis in opposition to a Judaic understanding of human nature, possibly even a threat to Judaism as practiced in their communities. The availability of psychological treatments in the secular world has raised the question for several Jewish authorities as to whether such treatment is useful or compatible with Orthodox Jewish belief and practice, and for some the answer is that

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secular psychology, particularly psychoanalysis, must be completely discredited and replaced with psychotherapeutic ideas and practices in line with rabbinic authority and Torah values. For example, Amsel (1970) in an article titled Judaism and Psychology opines: The implications of this conflict for the individual is the destructive influence psychology has exerted on our entire society. We are perpetually questioning: What is responsible for the shocking rise in juvenile delinquency, mental illness, drug addiction, alcoholism? We pour millions into research to find the answers.

We create new programs employing psychiatrists, social workers, and psychologists. Yet man’s situation grows progressively worse. Why? We fail to realize that Freudian psychoanalysis is at the root of the evils of our society. Let us state it as candidly as possible: We accuse psychoanalysis, with no reservations, as responsible for the decay of the moral standards of our society. It has poisoned and distorted the thinking of modern man on nearly every level and in every walk of life. It has influenced our educators, legislators, physicians and clergymen. Our attitudes and values are no longer the same. Marriage, sex, parent-child relations, social relationships-all have been tinted with psychoanalytic hues. How can we free ourselves from this chaos? The answer for the Jewish people lies in their re-adoption of the Torah and its 613 precepts. For mankind as a whole the answer lies in the re-adoption of the seven precepts given to Noah. (pp. 72-73)

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Similar opinions have been expressed by Schimmel (1977; 1997) who views Judaism and psychoanalytic psychotherapy as completely incompatible. There are two primary issues that seem to be problematic for these authors: The concept of psychic determinism and the orientation of psychoanalytic thinking toward the individual and individual expression. They accuse psychoanalysis of excusing and even encouraging immoral behavior by attributing it to uncontrollable unconscious urges for which the patient is not to be held responsible. For instance, Schimmel asserts that psychology denies the concept of free will which for Judaism is fundamental to human nature.

Psychology, he says, is based on assertions that “man’s thoughts, feelings, and behavior are completely determined by his biological heritage and by environmental influences over which he has little control,” and that “man’s reason as a tool for determining right and wrong is subject to great distortion by irrational forces of which he is not conscious.”

Thus, “the emotions of guilt, shame, and remorse are irrational in origin and are not conducive to psychological health.” Without shame and guilt, anything might be permitted (Cohen & Gereboff, 2004). Other authors (Klein J. , 1979) express concern that the individualism of psychology would undermine the coherence of a Jewish community.

They attribute secular psychologies orientation toward individualism to the influence of the Haskalah [Jewish Enlightenment] movement and view this emphasis on individual personal fulfillment as opposed to true fulfillment in the social life of an Orthodox Jewish lifestyle.

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For these Orthodox writers, Judaism is based on a received body of divine revelation and interpretation by recognized authorities whose work is to be studied and on the concept of Halacha [Jewish Law] as essentially a system of rules to be followed.

One learns to be Jewish by studying what authorities have said, and it seems to be expected that moral behavior will be clearly defined by these authorities. This point is underscored when Amsel describes an important aspect of what he calls “Torah therapy” as including informing the patient that she must learn that “our sages were wiser than us” (Amsel, 1976, p. 129) as part of her recovery from promiscuity. This emphasis on authority and rules lead these Orthodox writers to view psychology both as a secular science and a force promoting an individual relationship to morality and spirituality which is in opposition to Judaism (Cohen & Gereboff, 2004).

The anti-psychoanalytic stance is repeated from a Kabbalistic perspective, in a series of books by Gerald Epstein (1981; 1989; 1994). In an essay titled “What’s Wrong with Freudianism (1995),” Epstein asserts that the process of free association and psychoanalytic treatment leads to breaking commandments against dishonoring parents as well as bearing false witness and thus to lashon hara [evil speech] in general.

Epstein’s essay makes broad assertions about a truly Jewish orientation for psychology, such that it must be based only on perceptual reality and thus would not permit interpreting hidden meanings in dreams.

In practice, the abovementioned clashes between values, mores and practices of Orthodox Judaism and those of psychotherapy, are of great concern to the highly

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religious Orthodox Jewish rabbi as well (Goldsmith & Hansen, 1991). This is important to note because many studies have documented that clergy are often the first helping professionals contacted by people in crisis (Ingram & Lowe, 1989). Spiritual leaders of minority or ethnic groups that have strong religious traditions are widely accorded significant credibility as interpreters of the secular world and its institutions (Slanger, 1996). Consequently, the attitudes of these leaders toward psychotherapy and the mental health professions in general, will carry great weight and influence prospective patients’ views of psychotherapy and its practitioners.

Some of the areas of conflict between rabbis and therapists are similar to the concerns delineated by the literature above, and stem from the conviction that religious commitment and the mental health professions are based on inherently incongruous belief systems (Bulka, 1983). Therapists’ use of rational and scientific theories is considered anti-religious and heretical, thus making them untrustworthy. The deterministic concept of man in both psychoanalytic and behavioral theories is fundamentally opposed to religious Judaic thought, which stresses free will and accountability. Rabbinic authorities worry that sending people to a therapist might cause them to throw away their religion.

Additionally, for the Ultra-Orthodox rabbi, there is a concern about the laws of modesty and how it might be implemented during sessions, such as when a male psychotherapist treats an Ultra-Orthodox woman. According to Dr. Abraham J. Twerski, a retired Orthodox Jewish psychiatrist and a rabbi, Freud was understood to have claimed that people could solve their problems if they release themselves from repressions and

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inhibitions. As a result, members from the Orthodox Jewish religion – well known for its strict inhibitions – believed that Freud was approving of libertine behavior and were fearful lest the Orthodox Jewish patients leave their religion (Twerski, 2013).

The rabbi and mental health professional may also differ on crucial issues of whether an apparent religiously fastidious behavioral pattern should be properly classified as healthy or neurotic (Thomas, Cunin, Cunin, & Cunin, 1992). These real and perceived conflicts of theoretical principles and therapeutic applications can serve to alienate the rabbi and mental health professional, inhibiting good communication and impeding potential referrals to professional mental health services. The mental health practitioner, even if he does not personally champion these values, may be regarded in a similarly negative light simply by association. Indeed, Meir Wikler, DSW, who has written about treatment of Orthodox Jewish patients from the perspective of the Orthodox Jewish therapist, notes the skepticism toward them within the larger Orthodox community is only slowly dissolving. He states:

Freud viewed religion as a neurosis, as a symptom of mental illness, and unfortunately many of his disciples still believe that. So many Orthodox are apprehensive of therapists, even skeptical of our own religious commitment (2001, p. 63).

Furthermore, for the Orthodox Jewish rabbi, psychotherapy may be unacceptable because problems might be viewed as more of a moral-ethical implication and quite

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possibly stem from sin. A small minority endorse the idea that psychological disorder is solely spiritual in origin; the results of the machinations of the Yetzer Ha’ra (the evil inclination), and as the sole panacea for psychological disorders. These leaders suggest that religious faith, prayer, and other activities may be sufficient: We treat such problems in the community. We give the person with difficulties a boost, talking about belief, and trust in God, saying we must not despair... everything is from Heaven. We encourage him to listen to nigunim [Hasidic song], to read stories of miracles from the great rabbis (Greenberg & Witztum, 2001, p. 98).

Consequently, for some rabbis, emotional difficulties may be viewed as a result of not doing the will of God (“disobedience leads to madness�) and thus psychotherapeutic intervention may not be seen as relevant.

In sum, psychotherapy may be perceived by the Orthodox Jewish community as unacceptable for several reasons. Members of the community might perceive therapists as unknowledgeable of the beliefs, values, and mores of the community and prone to misjudge religious behavior and ideas. Own-group therapists as well, may be regarded suspiciously by association (Heilman & Witztum, 2000). Lastly, from the perspective of the mental health professional, Rabbis within the community are seen as obstructing congregants in their desire for mental health services. However, as mentioned, from the rabbinical perspective, there may be good reasons for minimizing the utilization of those services. In the following section, we go a step further by illustrating how many

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psychoanalytic concepts parallel and are reflected within Orthodox Jewish tradition, philosophy and thought.

Orthodox Judaism’s parallel relationship to psychoanalysis.

Although the relationship between Orthodox Judaism and psychoanalysis began precariously considering Freud’s perceptions of religion, many subsequent writers have suggested reconciliation (Eigen, 2012) by acknowledging the areas in which the two doctrines can mutually learn from each other. This may be especially true with respect to Orthodox Judaism which shares many similarities with psychodynamic/analytic psychotherapy (Strean, 1994). Bakan (1958) for example states that Freud was familiar with Kabbalah, and psychoanalysis was meant to “secularize Jewish mysticism.” In other words, Freud retained various aspects of the mystical Kabbalistic tradition, while replacing the religious framework with a psychological context. For example, both teach that having higher levels of self-awareness can improve self-esteem and that having mastery over impulses is an indication of maturity. The two are similarly founded on a system of knowledge, which is better acquired via a positive working relationship between teacher/therapist and student/patient (Drob, 2006). Both can be considered a persecuted minority struggling to survive within a larger community and within both there are many subgroups and divisions often at odds with each other (Drob, 1989).

Furthermore, despite the above cited literature on irreconciliation, there are several authors who have dealt with the Jewish roots of Freud’s ideas. They assert that

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several Freudian concepts are actually reflected in the Talmud and other areas of Jewish philosophy. Twerski (2010) points out that Freud’s idea of the pleasure and reality principles acting as the two opposing forces determining human behavior are concepts described in great detail within the Mussar writings [Jewish works on moral conduct, instruction, and discipline] originating in the Talmud. Furthermore, Twerski asserts that Freud’s pioneering of unconscious motivation was foreshadowed by the Torah requiring atonement for inadvertent sins. If the latter were purely accidental, why should a person be held responsible for them? Twerski concludes that it can only be because even inadvertent acts are motivated, but since one has no conscious awareness of his act, it can only be that it was motivated unconsciously. Freud’s concept of Thanatos, that just as there is a survival instinct in humans there is also a self-destructive/death instinct is supported by the Talmudic statement, “A person’s yetzer (an internal drive) renews itself daily and seeks to destroy him” (Babylonian Talmud Kiddushin 30a). The phenomenon of projection is alluded to in the Talmud which states, “if a person charges another person as being of illegitimate birth, his own status should be investigated, because a person projects his own faults onto others” (Babylonian Talmud Kiddushin 70a). Moreover, the Freudian tripartite model of the human psyche with varying forces pulling in different directions and the terms he used – ego (ich), superego (Über-Ich) and id (Es) – are remarkably similar to the terms Godly soul, animal soul and person (guf) described by Rabbi Schneur Zalman of Liadi, in his highly acclaimed work, the Tanya (Liadi,

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1796/1973) which describes the inner workings of the human soul and is largely founded on Talmudic and other rabbinic writings.

While many other similarities could be discussed, perhaps the most astonishing case to be made comes from Rabbi Shalom DovBer, the fifth Rebbe of ChabadLubavitch, who travelled to Vienna and underwent psychoanalysis with Freud, which he found helpful (Schneider & Berke, 2000). It is important to note the major significance of this event. A “Rebbe” is far greater than a Rabbi, the latter being described as someone with expertise in Jewish laws and practices. The Rebbe, on the other hand, not only possesses such revealed knowledge but is also an expert on the inner essence of life, the concealed knowledge, and is often the leader of hundreds, if not thousands, of followers.

The fact that a leader of such great caliber would seek to undergo psychoanalysis with Freud, speaks to the fact that under certain conditions and circumstances Judaism and psychoanalysis can be reconciled, sought after, and permitted.

Therapist’s View of the Beneficial Factors of Psychotherapy Thus far, the literature review has traced Orthodox Judaism’s current attitude toward psychotherapy and its practitioners from a historical and cultural vantage point and provided research from several Jewish sources that challenged some of the enduring misconceptions about Orthodoxy’s view of Freud, his ideas, and psychotherapy. Because this research project sought to discover what the Orthodox Jewish patient finds helpful about psychotherapy and its process, our discussion will now turn to the available

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research that discusses and identifies those therapeutic factors from the perspective of the therapist and theorist. Specifically, what does the literature say or speak about regarding what psychotherapists and theorists feel are the most important and beneficial factors in psychotherapy with their patients? What factors are identified? And finally, why do they feel that these factors are beneficial? The following section will explore and highlight several specific beneficial mechanisms that have been formulated within both, the classical and relational school of psychoanalysis. We conclude the discussion by exploring a third viewpoint about beneficial factors, namely the common factor model, which offers a pans-theoretical view about those factors which are deemed helpful to the patient’s healing process.

Theories of therapeutic action.

Since Freud’s initial attempts to comprehend the nature of what is viewed as helpful about psychotherapy, there has been a continuous debate about which factors are central to its therapeutic effect and how psychodynamic therapy works to benefit the patient. Theorists attempting to identify these factors have tended to polarize between two mechanisms as primary in promoting therapeutic change: (a) interpretation leading to insight, or (b) analysis of the present relationship and its corrective emotional implications. That is, some proponents of classical theory and technique suggest that change is contingent upon the resolution of intrapsychic conflict through transference

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interpretations while others argue that the therapeutic relationship itself serves as the most influential driver of change. This is demonstrated by Kernberg (2007) who presents an overview and comparative analysis of eight papers regarding what he refers to as the “therapeutic action” of psychoanalysis and which represent the complete range of modern psychoanalytic theories and approaches. Although he identifies three major issues that allows for comparative analysis, it is the first of these issues, namely, “what factors are being proposed as the therapeutic action of psychoanalytic treatment that determine its outcome” that is relevant for this discussion. The two dominant proposed factors identified by Kernberg’s comparative analysis are: understanding of unconscious conflicts and meanings, and the management of the interpersonal relationship that emerges during the course of treatment. At the same time, many psychoanalytic therapists accept the existence of several pathways to change besides the two aforementioned notions. Examples of these include mutative interpretations (Strachey, 1934), new-object relationship (Bibring, 1937), corrective emotional experience (Alexander, 1950), and self-object internalization (Kohut, 1984). In a brief discussion about psychoanalytic concepts of therapeutic effectiveness, Cooper (1989) concludes that there has been: a change of view from the earliest days of analysis, when a single therapeutic element was sought to explain the effects of analysis, to the present, when we see the therapeutic effect depending upon multiple interacting processes, none of which can be assigned clear priority in our present state of ignorance. (p. 24) Before proceeding to the literature, it is important to note that identifying

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beneficial and crucial therapeutic factors is a highly idiosyncratic process and dependent upon several factors. For example, several psychoanalytic theorists (Killingmo, 1989) have drawn a general distinction between what they call “oedipal” pathology and “deficit” (or “pre-oedipal”) pathology. The basic idea being that patients suffering from the usually less severe oedipal pathology require a therapy aimed at recovering (repressed) meaning and at changing an already established internal psychological structure, whereas the generally more severe deficit pathology calls for a more structured and supportive therapy aimed at constructing meaning and building up an internal selfstructure which the patient lacks. In this sense, any discussion aimed at locating the beneficial agents of change will depend upon the patient’s pathology and current level of functioning as well as the individualized selected goals of therapy (Gabbard, 2000), be they removing target complaints and symptoms or changing the patient’s character structure. Consequently, such considerations will have some bearing on what the crucial therapeutic factors are deemed to be. As Pine (1998) suggests, the mechanisms of change in analysis will always be individualized according to the characteristics of patient and analyst.

Emotional abreaction: Catharsis Early in the history of the establishment of the psychoanalytic movement, one of the questions persistently asked was, “What explains the therapeutic efficacy of effective

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approaches?” Freud’s metaphoric formulation of his work with Anna O. was “catharsis” which referred to extruding memories that were noxious or toxic. The emphasis then shifted to the abreaction and release of strangulated affect that had resulted when powerful emotions triggered by traumatic experiences overwhelmed the nervous system’s adaptive capacity at the time (Lichtenberg, 2012). In accordance with the classical psychoanalytic theory of drives, Freud and Breuer (1895) hypothesized that suppressed drives or affects resulted in psychological disturbance, especially hysterical symptoms.

They found that the patients’ symptoms disappeared when they were able to recall the precise event that triggered the symptom and aroused the accompanying affect and when the patient was able to discuss the event in a detailed manner, in effect putting what transpired in the past into coherent words (Freud & Breuer, 1895). This understanding of the nature of psychopathology meant that one of the main benefits of the talking cure was for the patient to uncover new ways of releasing blocked affects and drives, specifically through talk (Jørgensen, 2004).

Insight.

The idealization of “understanding” as being the primary route to emotional health, took root from the beginning of the psychoanalytic movement. Freud’s idea that the key to healing was to make conscious what had been unconscious derived both from his experiences of patients’ symptomatic improvements when they were able to

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remember and feel things they had consigned to the unthinkable and from a general scientific positivism that assumed that to understand something was to master it.

Contemporary analysts as well consider understanding and emotional insight to be of immense therapeutic significance (McWilliams, 1999). And so, a basic tenet of psychoanalytic theory is that insight is therapeutic and that the primary aim of psychotherapy is to know and not be preoccupied with the therapeutic goal (Yalom, 1980).

Along these same lines, Segal (1967) states that psychoanalytic insight is a precondition of any lasting personality change achieved in the analysis, and that all other factors are related to it. Insight, according to Segal refers to “the acquiring of knowledge about one’s unconscious through experiencing consciously and in most cases being able to acknowledge explicitly and verbally hitherto unconscious processes� (p. 83). For Segal, insight is therapeutic because it allows for the normal growth of personality via the reintegration of lost ego parts thereby resulting in a corrected perception of reality.

Additionally, insight is therapeutic because knowledge replaces omnipotence which enables the person to deal with his own feelings and the external world in more realistic terms.

Exposure, desensitization & changing passive into active.

The concepts of exposure, desensitization and changing passive into active is

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another beneficial aspect of psychoanalytic psychotherapy mentioned in the review literature (Jørgensen, 2004). This curative factor involves the establishment of, persistent repetition, reliving, and working through of the patient’s transference neurosis via the intervention of interpretation (Freud S. , 1914b). By exposing the patient to emotionally intense situations through the therapist’s continual clarification, interpretation, and confrontation of maladaptive social behavior, patients become desensitized to such situations as well as to the inner representations these situations are thought to originally trigger pathological behaviors. Hence, an improvement in the patient’s ability to handle such situations.

Furthermore, according to Freud’s theory of repetition compulsion, the human psyche undergoes repeated in vivo repetitions of pathogenic experiences and situations so as to process them (Freud S. , 1920) thereby changing the original passive position into a more active one. This process is mirrored in therapy, when via the therapists’ interpretations the patient is repeatedly confronted with feared situations without the expected catastrophic consequences. By doing so, the therapist allows the beneficial process of turning passive into active to unfold organically (Wolpe, 1969).

The role of interpretation.

Freud condemned, at least theoretically, all intervention other than interpretation, since such interventions are apt to blur the patient’s transference and therefore interfere

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with the clarity of the analyst’s vision and understanding (Segal, 1962). Furthermore, Kernberg asserts (1993; 2001; 2007), that a fundamentally interpretive approach is the all-important intervention of psychoanalysis and that the therapeutic relationship only acquires a therapeutic effect within that context, precisely because it is utilized to understand the patient’s unconscious conflicts. For Kernberg, the actual relationship with the psychoanalyst becomes a meaningful therapeutic factor only as a consequence of consistent transference interpretation. Strachey (1934) concurs and explains that through analytic interpretation the therapist shifts from being a transference copy of past objects, to a new object, which is a precondition associated with the corrective emotional experience to be described below (Orange, 2013; Frosh, 2016). From a traditional, realist epistemological stance, analytic interpretations help enable the patient to discern between archaic fantasy objects and real external objects in the present. By having insight into “the truth” about reality, the patient can be liberated and healed. Those adhering to the constructionist view, on the other hand, tend to believe that the effectiveness of interpretation lies with the idea that it allows for an effective and meaningful way of structuring reality (Orange, 2013; Frosh, 2016).

Relational theory.

While classical psychoanalysis locates therapeutic action in the analysis of the patient’s transference, relational psychoanalysis finds therapeutic action in the analytic

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relationship, emphasizing the reciprocal influence patient and analyst have on each other.

Just as Winnicott (1960) noted that an infant cannot be conceptualized apart from a maternal environment, Ogden (1994) has made a similar point regarding analysis: There is no such thing as an analysand apart from the relationship with the analyst, and no such thing as an analyst apart from the relationship with the analysand. (p. 63) Surveys conducted in several studies of psychotherapy and psychoanalysis, such as Wampold (2001) and Kachele (2014), demonstrate the central role interpersonal aspects play in comparison to technical features discerned from this or that theory. In other words, it is the working relationship or at least the quality of the relationship between patient and therapist, which serves as the most decisive factor in treatment (Triebel, 2007). Similarly, from a slightly different perspective Fairbairn (1958) suggested that: the disabilities from which the patient suffers represent the effects of unsatisfactory and unsatisfying object-relationships experienced in early life and perpetuated in an exaggerated form in inner reality; and‌ the actual relationship existing between the patient and the analyst as persons must be regarded as in itself constituting a therapeutic factor of prime importance. (p. 377) Consequently, from the relational perspective, the beneficial emphasis is not via interpretation or through insight, rather on creating new relational patterns. In other words, the patient is seen as bringing internalized relational patterns into the

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psychotherapeutic relationship. While old patterns will be repeated, it is most crucial that the patient have a new experience of relating based on this new relationship. In light of this, interpretation and verbally achieved insights are considered relational experiences, and interaction is itself is an interpretive process that conveys meaning. Thus, relational theory does not really put forward or assert a specific form of therapeutic activity but instead, calls for the recognition of unavoidable and continuous participation (Kantrowitz, 1995). As Ferenczi in Aron (1996, p. 140) suggests: “The analyst, like an elastic band, must yield to the patient’s pull, but without ceasing to pull in his/her own direction.” In the following paragraphs the writer will highlight some of the therapeutic factors seen as primary within the relational school of thought.

The corrective emotional experience.

An important beneficial factor associated with relational psychotherapy is the concept of the corrective emotional experience formally introduced by Franz Alexander and Thomas French (1946). According to these theorists, psychopathology is the consequence of past and present pathogenic interpersonal relations, whereby the patient’s repetitive interpersonal maladaptive patterns prevent more authentic ways of relating to others. Within the therapeutic relationship, the patient reenacts old and outdated relational patterns, whereas the reactions of the therapist (ideally) break those patterns by conforming not with the expected behavior of significant others in the patient’s life but

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with the actual therapeutic situation in the here and now. “The crucial therapeutic factor is that the [therapist’s] reactions are different from those of the parents” (Alexander, 1950, p. 486). When the patient is exposed, under more favorable circumstances, to emotional situations that he or she failed to handle in the past, the patient is offered the opportunity to undergo a corrective emotional experience, which can lessen or heal the negative effects resulting from previous pathogenic experiences (Alexander & French, 1946, p. 66). Gradually, the therapist will “help the patient both to see intellectually and to feel the irrationality of her emotional reactions” (Alexander & French, 1946, p. 67).

The helpful aspect of the corrective experience is highlighted by Fairbairn (1958), as well when describing the patient-therapist relationship.

He writes: The patient-therapist relationship provides the patient with an opportunity, denied to him in childhood, to undergo a process of emotional development in the setting of an actual relationship with a reliable and beneficial parental figure (p. 377).

In short, for these theorists, the therapist uses the therapeutic relationship to disconfirm the dysfunctional beliefs held by the patient about interpersonal relationships and compensates for frustrations and traumatic experiences in past relationships.

Although the term ‘corrective emotional experience’ fell into disfavor in classical analytic circles for reasons beyond the purview of this literature review, Kohut and others have used it differently than Alexander. Kohut (1984), Bacal (1985), as well as Paul Tolpin (1983) use the term corrective selfobject experience, to assert that the

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internalization, structuralization, or representation of the cohesion-fostering selfobject relationship is the therapeutic, “corrective” experience in psychotherapy. Kohut believed that the major beneficial aspect of psychoanalysis is the strengthening of the self that results from structuralization or, “the laying down of psychological structure” (Kohut, 1984, p. 98). Indeed, according to self psychological theory, strengthening the self takes precedence over all other possible therapeutic objectives such as making the unconscious conscious, resolving conflict, remembering, reconstructing, or unifying aspects of the self (Wolf, 1988). Through the corrective selfobject experience the pathological aspects of the patient’s self-organization is altered (Lessem, 2005) primarily via the selfobject transferences. The corrective selfobject experience is fostered by the patient’s repetitive experiencing of the therapist’s responsiveness as helping him to co-create the selfobject experiences that were insufficient in childhood. The establishment and – following the occasional, inevitable disruptions – repeated reestablishment of the selfobject relationship strengthens the self and promotes a sense of entitlement to, and confident expectation of, being reliably listened to, responded to, and understood. In other words, the corrective selfobject experience results in the confident expectation that one’s psychological needs will be met (Bacal, 1990).

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Relational ruptures.

Recently, Safran and Muran (2000) have focused on the dynamic of the working through relational ruptures as the main benefit associated with effective psychotherapy.

According to the researchers, continuous examination of the subtle elements in the patient-therapist interaction and the repairing of alliance ruptures could: Provide a learning experience through which the patient gradually develops an interpersonal schema that represents the other as potentially available and the self as capable of negotiating relatedness even in the context of interactional ruptures (Safran, 1993, p. 19).

Similar to the classical psychoanalytic notion of working through negative transferences, the patient tends to reenact maladaptive patterns of behavior with the therapist. The therapist’s success in working through the reenacted interpersonal conflicts, will contribute significantly to the patient’s positive development by demonstrating healthier ways of addressing conflict. Thus, the non-repetition and working through of maladaptive interpersonal patterns in therapy represents an important and extremely beneficial factor of psychotherapy (Cates & Broome, 2016). \Mentalization and the ability to handle interpersonal interaction.

The concept and development of mentalization is another highlighted beneficial dynamic and aspect of psychotherapy. According to Fonagy (2002), “psychotherapy in all its incarnations is about the rekindling of mentalization” (p. 368), and every

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psychotherapeutic process can have an effect on the development of a mentalizing capacity, whether slightly or significantly. Mentalization allows a person to be more in tune with others’ thinking, thereby enabling them to “read” and understand their minds.

As a result, they can predict others’ actions better through “inferring and attributing causal intentional mind states to them” (p. 347), which is a crucial for testing social realities and developing normative relations with others. The therapist represents the patient as an intentional and mentalizing agent with understandable and acceptable thoughts, feelings, and desires. Thus, the patient is able to find, rediscover, or recognize herself in the therapist’s view of her and to internalize the therapist’s representation of her as a significant part of her own developing self. When the patient finds an image or reflection of her own mental state in the mind of the therapist, what she encounters is a processed version of her mental state, a version that she finds containable and bearable.

Melanie Klein (1946) and Wilfred Bion (1963) described this process as the therapeutic use of projective identification (Ogden, 1982), whereby the therapist contains and metabolizes the strong and negative emotions the patient cannot handle and process. Akin to this, Winnicott (1971) wrote that the essence of “psychotherapy is not making clever and apt interpretations; by and large it is a long-term giving the patient back what the patient brings” and “if I do this well enough the patient will find his or her own self, and will be able to exist and to feel real” (p. 117).

In sum, the preceding paragraphs have shown that even among those who remain convinced of the value and importance of Freud’s revolutionary findings and theories, the

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idea of what factors constitute as beneficial within psychoanalytic treatment has broadened since the early days when interpretation alone was considered primary (Fonagy & Target, 2002). Specifically, the primary importance of affective-attachment, creating support and promoting growth through a benevolent presence, or a focus on the relationship has been highlighted. Furthermore, other beneficial therapeutic factors, including the importance of the recovery of a good object in the analyst, how the analyst behaves in relation to the patient, the corrective impact, and others, have been reviewed and well founded. Viewed this way, these contributions can be ordered on a continuum from one polarity, privileging interpretation as the valuable psychoanalytic intervention, to the opposite polarity, in which an appropriately managed relationship is considered the most important therapeutic factor in the treatment (Kernberg, 2007). And yet, understanding the factors that are responsible for the benefits of psychotherapy, continues to prove to be exceedingly difficult (Kazdin, 2009). The ongoing quest for the solution to the question “What specifically is it about psychotherapy that makes it so helpful?” has fueled research and debate for more than five decades, aptly termed by Duncan as “the great battle of the brands” (Hubble, Duncan, & Miller, 1999), in that “psychoanalytic, behavior, humanistic, cognitive, and other therapies were pitted against each other” (Duncan, 2002, p. 35). With the research indicating “little evidence to recommend the use of one type of therapy over another” (Norcross & Goldfried, 1992, p. 9) and the huge amount of data showing no significant differences among the different treatments that exist for psychological distress (Wampold, 2001), researchers shifted their attention from

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a “mine’s better” focus (Garfield, 1992), and attempted to pinpoint the pans-theoretical elements that made treatments effective. The organizing question shifted and became, if specific models cannot explain why therapy works, then what does? In the following section, we review alternatives to understanding psychotherapy from a specific theoretical orientation and focus instead on what has been referred to as the “common factors” of psychotherapy. That is, factors which are not theoretically anchored in the treatment models of the different schools of psychotherapy.

The common factors model.

According to Arkowitz (1992), dissatisfaction with individual theoretical approaches led to the creation of three movements: theoretical integration, technical eclecticism and common factors. Over the years, there have been several theoretical presentations of the common factors. The common factor models have nevertheless existed on the periphery, with their greatest acceptance coming during the period when humanistic treatments, with which they were most closely aligned, were also relatively popular. Understandably, advocates of particular treatments have assiduously resisted the common factor explanation because its acceptance as the cause of the benefits of psychotherapy would collapse the entire scaffolding of the theoretical bases of modern psychotherapy as conceptualized by the field and presented to the public. Consequently, the field of psychotherapy has attempted to establish the primacy of treatment through the

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use of placebo-type control groups and other designs, to rule out common factors as the critical component explaining the benefits of psychotherapy. Nevertheless, a countervailing, although weak force already existed in the early history of psychotherapy, which claimed that the efforts to establish the best treatment were misguided. In 1936, Saul Rosenzweig noticed that despite the differences among the various therapies of that time, the outcomes were generally similar. In what came to be known as the “Dodo Bird Verdict” (referring to the race in Alice’s Adventures in Wonderland (Carroll, 1865), in which the Dodo Bird issues a competition between characters to run around the lake until they were dry, without anybody caring to calculate the distance nor time each person spent running. When the Dodo was asked who had won, he thought long and hard and replied, “Everybody has won and all must have prizes.”), Rosenzweig hypothesized that despite the competition among the various psychotherapies, all psychological treatment methods are equally effective. He states: What… accounts for the result that apparently diverse forms of psychotherapy prove successful in similar cases? Or if they are only apparently diverse, what do these therapies actually have in common that makes them equally successful? … it is justifiable to wonder… whether the factors that actually are in operation in several different therapies may not have much more in common than have the factors alleged to be operating. (pp. 412–413) Essentially, Rosenzweig was seeking answers to: (a) whether factors that supposedly are operating in a given therapy are identical to the factors that actually are in

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operation, and (b) whether the factors characterizing various therapies may actually be more similar to each other than the factors alleged to be in operation. He concluded that because no form of psychotherapy is without its successes, its supremacy cannot be reliably considered evidence to the validity of its theory. Rather, there might be some potent implicit common factors, perhaps more important than the methods employed, which explains why divergent methods could claim success. Nearly two decades after Rosenzweig’s first study, Paul Hoch echoed Rosenzweig’s words in a 1955 article: If we have the opportunity to watch many patients treated by many different therapists using different techniques, we are struck by the divergences in theory and in practical application and similarity in therapeutic results… There are only two logical conclusions… first that the different methods regardless of their theoretical background are equally effective, and that theoretical formulations are not as important as some unclear common factors present in all such therapies.

(Hoch, 1955, p. 323) Rosenzweig ultimately suggested several possible “common factors,” including: 1. unverbalized processes within the therapeutic relationship, which spurred social reconditioning, 2. catharsis, 3. favorable and dynamic aspects of the therapist’s personality, and 4. the “formal consistency” which the therapist conducted in treatment using

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a system of concepts that impacted the patient’s psychological issues.

Since Rosenzweig’s original proposal that common factors are what produce the benefits of psychotherapy, many attempts have been made to identify and codify what the common factors are and how they work.

Frank’s model.

One of the most comprehensive models of the common factors was first developed in the 1960s by Jerome Frank and presented in his book Persuasion and Healing (1973) which was entirely devoted to the commonalities cutting across approaches. Frank incorporates much of Rosenzweig’s work and provides an expanded theoretical and empirical context, particularly concerning the major influence that hope and expectancy have as healing factors, which within the literature has been labeled the “placebo effect” and will now be elaborated upon.

According to Frank and Frank (1991), people present for psychotherapeutic treatment because of the demoralization associated with their symptoms rather than for symptom relief. Demoralization is associated with subjective feelings of incompetence, isolation, and alienation. Ultimately, this results in a significant loss of self-esteem and feeling of hopelessness. Psychotherapy achieves its effects by treating demoralization directly while indirectly treating “overt symptoms of covert psychopathology” (Parloff, 1986, p. 522). Frank and Frank (1991) assert that all effective therapies share four

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common features that address feelings of demoralization. A successful therapy provides: 1. an emotionally-charged, confiding relationship with a helping person. The relationship/alliance has long been regarded as an essential component of therapy and in their literature review, Grencavage and Norcross (1990) found it to be the commonality most frequently endorsed; 2. the second beneficial component, a healing setting, is a special location regarded by the patient as a place of safety, security, and apt for recovery; 3. A third feature of successful therapies is that of a rationale, conceptual scheme, or “myth” that plausibly explains the patient’s symptoms and prescribes a ritual or procedure for resolving them; and 4. the strong belief held by the patient and therapist that the prescribed ritual or procedure can restore the patient’s health. Frank (1973) refers to this final factor as “remoralization” which speaks to the ability of hope in that the client believes that the therapy can be effective.

During the 1970s, theorists (Shapiro, 1971; Shapiro & Morris, 1978) picked up on Frank’s far-reaching discussion of hope and expectancy and studied its effects within the context of the placebo, namely what one expects in a certain situation has a strong influence on what the person experiences (Plassmann, O’Doherty, Shiv, & Rangel, 2008).

Indeed, as early as 1905, Freud already stated that, “expectation colored by hope and

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faith is an effective force with which we have to reckon‌ in all our attempts at treatment and cure� (Freud S. , 1918, p. 289). Subsequent research has borne out his statement by addressing the importance of assessing what clients expect on entering treatment and how those expectancies may impact the progression of subsequent treatment. (DeFife & Hilsenroth, 2011).

The idea that expectation is helpful in psychotherapy and a prominent common factor can be understood in several possible ways. Frank indicated that clients seek out psychotherapy when demoralized not only because they are distressed but because they have been repeatedly unsuccessful in their endeavor to overcome their problems. Taking action by seeking help from a psychotherapist is another form of seeking a solution, one that a patient will often believe will be beneficial. The very act of arranging psychotherapy seems to be ameliorative, and much benefit is realized between the time the appointment has been set and the first session occurs. The positive effect of believing that engaging in psychotherapy will assist in life will being better, is remoralizing according to Frank. These curative effects, therefore, are not thought to derive specifically from a given treatment procedure; they come from the positive and hopeful expectations that accompany the use and implementation of the method. Indeed, Kottler (1991) writing from this perspective states that any technique from any model may be viewed as a healing ritual, rich in the possibility that hope and expectancy can inspire.

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Summary.

In conclusion, the last decades of literature have produced conflicting reasons as to what constitutes the beneficial aspects within psychotherapy treatments from both theorists and therapists’ perspectives. Apart from the idea that certain specific factors can indeed produce a healing effect, the studies have also highlighted certain unspecific factors play a beneficial role in the process. These inconclusive findings and differences in perspectives have generated an expansion of studies designed to explore both modelspecific factors and those aiming to uncover pans-theoretical elements. Several common factors have been identified, which Hubble et al. (1999) condensed into four themes and accompanying percentage variances.

1. Patient/therapeutic factors – referring to patients’ strengths as well as other supportive elements. According to Hubble et al. (1999), these factors explain 40% of the outcome variance in therapies’ success.

2. Relationship factors – refers to elements such as care, empathy, warmth and acceptance. Hubble et al. claimed that these factors account for 30% of the outcome variance.

3. Placebo, hope and expectancy – refers to beliefs that both the therapist and patient have with regard to the capabilities of the treatment to heal. These factors can explain 15% of the outcome variance (Hubble et al., 1999).

4. Model/technique factors – refers to the unique factors found within different therapies, which explain the remaining 15% of outcome (Hubble et al., 1999).

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Research has shown that the therapeutic factors valued by patients may differ greatly from those cited by therapists and researchers. Indeed, Satran (1995) asserts that the disparity between how patient and therapist view what is and was significant seems more the rule than the exception. As a result, if psychotherapy researchers, theoreticians and practitioners want to have a higher level of comprehension about the process and action of psychotherapy, they need to be familiar with the kind of experiences that patients have when undergoing psychotherapy treatment. Since patient factors account for 40% of the outcome variance as per Hubble et al. (1999), it is crucial that researchers in this field focus on this central factor, which will now be reviewed in the following section.

Patient’s View of the Beneficial Factors of Psychotherapy Seeking out the patient’s perspective of their treatment is not a new idea.

Historically, the first description of a patient’s view of therapeutic action in psychotherapy can be traced to Breuer and Freud, in their seminal work entitled Studies in Hysteria (1895). When Breuer’s patient Anna O. described her treatment as “the talking cure” and characterized the therapeutic process as “chimney-sweeping” (p. 30),

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implicit in her words was how she experienced the curative factors associated with her treatment. Ultimately, her descriptions led Freud to develop the theory of “cathartic cure” (Lilliengren & Werbart, 2005). More recently, Erikson (1962) as well touched upon the subject of what the patient wants or finds beneficial in treatment when he asked, “what did Dora want from Freud back in 1900?” Erikson postulates that Dora wanted her experience validated as opposed to Freud who believed the problem with the case was his failure to interpret the transference. For Erikson, this highlighted the frequently overlooked consideration of the patient’s persistent world view that operates despite the theory and techniques of the therapist (Reiss, 1988). It was for this reason that Milton Erickson (1980) railed against imposing therapist’s theories on patients. He instead advocated “utilization”: Exploring a patient’s individuality to ascertain what life learnings, experiences, and mental skills are available to deal with the problem… [and] then utilizing these uniquely personal internal responses to achieve therapeutic goals (Erickson & Rossi, 1979, p. 1).

In a similar vein, Kohut was quoted as saying: “The patient, as I finally grasped, insisted – and had a right to insist – that I learn to see things exclusively in his way, and not at all in my way (1984, p. 182).” Frank and Frank suggested that “ideally therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem” (1991, p. xv).

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Despite this and the fact that patients know or at least have a variety of feelings and ideas about what is and has been helpful during treatment (Satran, 1995), studies focusing mainly on the patient’s perspective and inner views are very limited (McLeod, 1998; Bowman & Fine, 2000; Gaddis, 2004), making what patients’ experience during their therapy sessions and what they believe was beneficial, distant from the practitioner (Ribner & Knei-Paz, 2002). Gaining access to an “inside” view (Wynne, 1988) could improve the therapy processes in general and prompted Satran (1995) to propose better examining or scrutinizing the patient’s therapy experience by asking periodically what they felt was helpful to them. Ferenczi (1932) in his diaries noted that if patients are encouraged to speak, “you will hear much that is instructive” (p. 118). He concludes: I am aware of the modest, even ordinary nature of my proposal, as well as the fact that many of us do something of the sort. But, because the therapeutic action of analysis with all its magic and mystery ultimately belongs to the patient, we owe our patients and ourselves the keenest possible appreciation of the patient’s sense of what is helpful. (p. 118) Patients’ reports of their experiences can serve as a rich and relatively untapped source of important information (Zuroff, Shahar, Blatt, Kelly, & Leybman, 2016). After all, it is their experience, theirs alone, and the farther we move from the patients’ experience, the more inferential are our conclusions. To be sure, there are aspects of the process of change that operate outside a patient’s awareness, but it does not follow that we should disregard what patients do say.

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Historical account.

While accounts of therapy in the words of patients are comparatively rare (Kantor & Andreozzi, 1985), since the 1960s there have been several studies into the patients’ perspective on helpful aspects in therapy (Grafanaki & McLeod, 1999; Llewelyn, 1988; Strupp, Fox, & Lessler, 1969). For the most part, the interest in patients’ experiences of psychotherapy as a valuable focus for research dates back to the early days of Rogerian psychotherapy and, more specifically, to Lipkin’s (1948) study of 37 male patients in person-centered therapy who were asked to describe their experiences of what had brought them to therapy, the therapy itself, and the changes following it (Zuroff, Shahar, Blatt, Kelly, & Leybman, 2016). As part of the ongoing reaction against the dominating quantitative and experimental orientation in psychological research, the 1950s and 1960s introduced patient and therapist versions of rating scales and questionnaires, which allowed for both the objective study of patients’ and therapists’ subjective experiences, and comparisons of participants’ and researchers’ perspectives (Orlinsky & Howard, 1967; Snyder, 1961; Strupp, Fox, & Lessler, 1969). Presently, this area of research has grown substantially and encompasses a wide range of approaches to define, capture and analyze patients’ experiences of important factors and processes in different types of therapy.

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One specific area where perceptions of participants have been more fully considered is within studies of qualitative nature, which allows for the discovery of phenomena without data reduction that may obscure meaningful distinctions (Ponterotto, 2002). These studies, which use methods such as interviews or focus groups, allows its participants to provide accounts of their experiences and perceptions, as opposed to quantitative studies that mostly used numeric data and statistical methods. In this tradition, the researcher’s close proximity to participants facilitates a genuine interest in learning and understanding about experiences, whilst making transparent the researcher’s biases and expectations. The qualitative literature concerned with patient perceptions of therapy reveal that studies have focused on: patient views of their therapists and the therapeutic relationship (Rennie, 1992; Wark, 1994); children’s perspectives on their family therapy experiences (Bischoff & McBride, 1996); comparisons of patient and therapist perceptions of therapy (Bennun, Hahlweg, Schindler, & Langlotz, 1986), patients’ views of their treatment at various points during the therapy process (Gale, Odell, & Nagireddy, 1995); “significant events” within a given therapy session (Elliott & Shapiro, 1992), and “effective moments” throughout the course of therapy (Sells, Smith, & Moon, 1996). In the section to follow we highlight the qualitative research concerned with patients’ specific experiences of therapy and what they identified as most beneficial within their psychotherapeutic experience.

Helpful factors research.

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Within the literature, there are several qualitative studies on patients’ experiences of helpful factors that exist within their therapy sessions. One method that has been used to assess the experiences of the patients is Viklund’s (2013) “helpful factors research,” which asks patients to describe in detail what they found most helpful and important in the course of their therapy. The data is qualitatively analyzed and categorized into overviews of types of helpful factors, by defining, describing, labeling and categorizing the data in accordance with established qualitative research methods.

For example, in a pioneering study by Elliott (1985), university students voluntarily partook in a 20-minute mock counseling session and were then asked to describe what they found helpful about the therapist responses. Cluster analyses identified eight kinds of helpful events which were grouped into two superclusters that corresponded to task and interpersonal aspects of helping interactions. The predominant cluster in the task supercluster was ‘new perspective’ and included ‘problem solution’, ‘clarification of problem’, and ‘focusing attention’. The predominant cluster in the interpersonal supercluster was ‘understanding’ which included ‘patient involvement’, ‘reassurance’, and ‘personal contact’. The use of pseudo-patients engaged in a brief session was acknowledged by the researcher as a limitation of the study.

In addition to the above study, Elliot and James (1989) carried out a metasynthesis of the first four decades of research available at the time involving patients’ experiences of their therapy sessions and their perceptions of the helpful aspects.

Through different kinds of methodologies, the researchers summarized their findings

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under five different categories of helpful aspects of therapy which were then further categorized into two broad categories: relationship/affective factors and task/problemsolving factors. Under the broad category of relationship/affective factors, the most cited helpful factors included facilitative therapist characteristics, the chance to speak freely, and the opportunity to experience a supportive relationship with an expert. Under the second category, the most helpful factors cited by the patients were gaining a better selfunderstanding and the opportunity to receive encouragement from the therapist to carry out skills and insights in their daily lives. The researchers noted that their review was limited by the use of indirect measures of patient experience developed to assess what investigators think are important about patient experiences and they called for future researchers to use a more qualitative measurement of patient experience and exploratory research. In another study, Llewelyn (1988) reported on helpful and unhelpful events in therapy identified from the Helpful Aspects of Therapy questionnaire. 40 therapist-client pairs were asked to record, after each session of psychotherapy, their views concerning the helpful and unhelpful events which took place. On termination, they were asked to depict their views of the helpful and unhelpful events in retrospect. Elliott’s Therapeutic Impact Content Analysis System was used to analyze the content from a total of 1076 events that transpired over 399 therapy sessions. Participants identified four therapeutic ingredients; insight, reassurance/relief, problem solution and personal contact, which differed from therapists’ reports. During therapy, patients found helpful ‘the reassurance and relief provided by therapy’ and, in retrospect, valued most the problem-solving

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aspects of therapy, whereas therapists cited cognitive and affective insight as being the most helpful. Llewyn concluded that poorer outcome was often linked to the differing perceptions of the therapist and the patient. These findings are similar to other studies where non-specific factors are emphasized by patients as most helpful. For example, Glass and Arnkoff (2000) identified patients’ perceptions of the therapeutic relationship and the type of interventions perceived as most beneficial. Results revealed that for the patients, the most helpful element was having a therapist who listens and exhibits understanding. Patients also valued a ‘collaborative relationship’ whereby the therapist saw the patients beyond a diagnostic to the whole person. Problem-solving skills and encouragement were also seen as helpful. Particular interventions were not identified, rather patients highlighted the value of non-specific factors. Both studies appear to confirm earlier psychotherapy research which has demonstrated significant differences between the patient and the therapist’s view of psychotherapy (Mintz, Auerbach, Luborsky, & Johnson, 1973). Specifically, patients appreciate talking to a neutral person and describe events and relationships in their everyday life as helpful, while the therapists emphasize their technical skills and insight, neglecting exogenous factors (McLeod, 1990a; 1990b). The patients attribute therapeutic success to the therapist’s positive regard and warmth, while therapists attribute success to their interventions (Weiss, Rabinowitz, & Spiro, 1996). Thus, the patients seem to focus on the common or nonspecific factors while the therapists focus on specific factors.

Several other investigators have concentrated on identifying and understanding

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patients view of helpful events in therapy. For instance, Martin and Stelmaczonek (1988) matched patient reports of important events in counseling to Mahrer and Nadler’s (1986) categorical system of “good moments in psychotherapy” and found that patients rate events that involve expressions of insight and understanding, provisions of personal material, descriptions and explorations of feelings, and expressions of new ways of being or behaving as important. In a study of patients’ helpful experiences of counseling, Paulson, Truscott, and Stuart (1999) interviewed 36 patients who had completed counseling after an average of 11 sessions. Utilizing qualitative and quantitative strategies, the researchers identified five thematic clusters consistent with previous research: Counselor Facilitative Interpersonal Style, Counselor Interventions, Generating Patient Resources, New Perspectives, and Patient Self-Disclosure. Four new thematic clusters were also identified: Emotional Relief, referring to the expression and release of emotions as a helpful agent, Gaining Knowledge or gaining new information and learning new interpersonal skills, Accessibility referring to the availability and affordability of counseling, and Patient Resolutions or being able to achieve what was desired and being able to return to counseling if needed. The authors conclude that overall, the role of the therapist’s interpersonal style and the role of the therapeutic relationship emerged as helpful elements in the therapy process. The researchers also make a point of noting that the most highly rated helpful aspect of therapy was affordability which suggests that financial considerations play a more important role than has been previously recognized.

Similar factors have been described in other reviews. For example, Howe (1993)

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mentions patients frequently report that experiencing the therapist as warm, friendly, genuine, interested and accepting, getting the opportunity to express experiences and to explore thoughts and feelings and make sense of them as the most beneficial aspects of therapy. Greenberg et al. (1994) organized the five most frequently described or strongly rated helpful aspects from 14 studies of helpful factors in person-centered experiential therapies. The researchers found 14 types of helpful aspects which they organized into four groups: positive relational environment (e.g. empathy), patient’s therapeutic work (e.g. exploration), therapist facilitation of patient’s work (e.g. giving feedback, fostering exploration), and patient changes or impacts (e.g. experiencing positive feelings, gaining insight/awareness). Rennie (2002) reviewed grounded theory studies on patients’ beneficial experiences in humanistic therapy and found that patients identified the therapist’s guidance as helpful so long as it was in line with their hopes and expectations.

Timulak (2007) conducted a qualitative meta-analysis of seven studies of patientidentified helpful events in a mixture of therapies. He found nine categories that replicated across studies. The most prevalent were awareness/insight/self-awareness and reassurance/support/safety, which occurred in all seven studies. Behavior change/problem solution, exploring feelings/emotional experiencing and feeling understood occurred in more than half of the studies. Binder, Holgersen and Nielsen (2009) conducted a study to identify the specific experiences and reflections of former psychotherapy patients who described their previous therapy as successful. Utilizing semi-structured, qualitative, indepth interviews with ten former psychotherapy patients, a phenomenological approach

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was used to analyze interview transcripts. They found that the different ways the participants gave meaning to change processes and events clustered around the following themes: 1. Being in a relationship with a wise, warm, and competent professional, 2.

Being in a relationship with continuity when suffering from feelings of inner discontinuity,

3. Having assumptions and beliefs about oneself and one’s relational world corrected, and 4. Creating new meaning and seeing new connections in one’s life patterns.

Based on their findings the authors conclude that the therapist as a person and his/her interpersonal and communicative competence is a strong predictor of therapeutic outcome. Of note, the therapist’s particular theoretical orientation did not seem very important to participants. More recently, Krohn (2016) conducted a study using a case study methodology designed to explore the subjective experiences of five participants who engaged in psychotherapy as emerging adults and what they specifically found helpful or not helpful in treatment with their therapists. He found that participants appreciated a new relational experience that contributed to them viewing their therapists mostly as supportive, who helped them develop self-understanding, and relinquish ties to unconscious relational models that helped them operate in new, different ways with

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intimate others. The patients appreciated the therapeutic relationship as a means of identifying, articulating, and working through parental relationships as part of the developmental task of individuating from parents. These participants reported that their experiences within the therapeutic relationship and how their therapists handled or mishandled the relationship constituted the most salient factor in contributing to how they viewed therapeutic action, and what they found helpful (or not helpful) in treatment.

Some reviews in the research literature focus on helpful factors which include therapies of different theoretical orientations, e.g. cognitive-behavioral, eclectic/mixed, emotion-focused, experiential, humanistic and psychodynamic therapies (Viklund, 2013).

The results from these studies indicate that patients in different types of therapy may, to some extent, report different types of helpful factors, in some cases with the events matching the theory underlying the therapeutic approach. For example, Llewellyn, Elliott, Shapiro, Hardy, and Fitz-Cozens (1988) reported that “awareness” was a typical benefit reported in psychodynamic therapy whereas in prescriptive therapy, such as the cognitive-behavioral orientation, a typical benefit reported was “problem solution.” In a more recent study, Nilsson, Svensson, Sandell, and Clinton (2007) compared patients’ experiences of therapy in cognitive-behavioral (CBT) treatment and psychodynamic therapy (PDT) and their level of satisfaction. The authors found that there were roughly equal numbers of satisfied and unsatisfied patients in both types of therapy, and that there were both similarities and differences in the experiences reported by the patients in each type of therapy. Satisfied patients in both forms of therapy reported that they had found

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new coping tools that helped them to better cope with anxiety and that they had become better at coping with and understanding feelings. The CBT group of patients experienced a regained sense of being a normal person and were better able to cope with their difficulties. Reported helpful factors included the therapists’ expert knowledge of how to achieve the therapeutic goals and the patients’ willingness to expose themselves to frightening things, and exercises. Within the psychodynamic group, satisfied patients experienced better self-understanding and the ability to put together a more coherent life story. Helpful factors reported by PDT-patients included being able to talk about and reflect on themselves, and the various aspects of the relationship with the therapist, such as the therapist was emotionally supportive, nonjudgmental, accepting and professional.

Within the field of couple’s therapy as well, there have been several studies conducted examining patients’ subjective experiences of treatment. Greenberg, James, and Conry (1988) asked couples in emotionally focused couples’ therapy (EFT) to identify helpful and hindering incidents and to describe how change occurred. Sells, Smith, and Moon (Sells, Smith, & Moon, 1996) interviewed patients about their perceptions of therapy effectiveness. Christensen, Russel, Miller, and Peterson (1998) asked patients in marital therapy to describe therapist facilitating behaviors and turning points in therapy and Helmeke and Sprenkle (2000) asked patients in couples’ therapy to describe pivotal moments. Bowman and Fine (2000) asked couples who were in, or had newly completed, couples’ therapy what they perceived as helpful and unhelpful about their therapy experiences and regarding the therapist’s activities. The findings in all

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studies are similar and point to three types of processes and impacts that patients found helpful and important for a successful treatment: First, patients found emotional experiencing, hope, and a sense of safety helpful. This includes feeling validated by one’s partner or other family members, which is a factor specific for couples and family therapy. Second, patients experienced cognitive change, insight and awareness as helpful and, third, they experienced a strong connection with a caring, competent therapist who was well attuned to their presenting problems as helpful.

In short, much of the research on patients’ views of what factors benefitted them most has demonstrated the presence of two broad types of helping factors which seem to cut across therapy modalities: Patients often seem to find common relational factors helpful, for example the opportunity to talk freely to a competent, supportive, accepting, genuine, empathic and attuned therapist. Patients also seem to find factors related to problem-solving and the tasks/techniques of therapy helpful, for example gaining insight/awareness, and finding new tools to cope with or solve their problems. In general, patients seem to appreciate therapists for their skill and experience, for treating them with respect, understanding, and as an intelligent person. They liked explanations or interpretations that provided them with new ways of looking at their situations and they appreciated being told they were competent, skillful, insightful people, in contrast to being regarded as fragile, failures or unable to cope.

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Summary.

The APA report on Evidence-Based Practice in psychology (2006) maintains that qualitative research can strengthen the relation between practice and research by describing the subjectively lived experience of participants in psychotherapy which can then help identify conditions that maximize clinical expertise. While there are qualitative studies focusing on change and outcome in psychotherapy (Howe, 1996; Midgley, Target, & Smith, 2006), none of these studies has focused solely on what patients themselves identify as helpful. More studies investigating how patients themselves give meaning to the many aspects of therapeutic change are needed (McLeod, 2001). The preceding literature review supports the view of Rowan (1992) and Mahrer (1985) in that understanding is limited by our attempts to isolate and manipulate experimental variables, rather than be concerned with talking with patients and exploring how they make sense of their experience. Yet, the aim of psychotherapy is to help patients through creating and sustaining meanings. In order to conduct inquiry concerning these meanings it is necessary to explore these issues with those involved. As Hodgetts and Wright (2007) state, “Now may be an appropriate time to talk to our patients.� This is especially true as it pertains to the Orthodox Jewish patient. To date however, there have been virtually no studies which describe the beneficial aspects of psychotherapy experience from the

perspective of the Orthodox Jewish patient, the subject of this study. In the next section,

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our discussion turns to the one study most similar to the current research project.

Orthodox Jewish Patient’s View of the Beneficial Factors of Psychotherapy The last study highlighted in this literature review is one that is most similar to the current study. This is a qualitative exploratory study in which the researcher examined the experiences and attitudes of three Orthodox Jewish female patients in psychotherapeutic treatment. In describing the rationale for her study, Starck (2008) argues: To date, most of the literature on working with ethnic minorities has focused on those groups which are most sizable, including African-Americans, Asians, Latinos, and Indians. The Jewish population, a group small in size relative to other minority populations, has often been excluded from consideration in discussions of multiculturalism and its implications. It is essential, then, that an understanding of Orthodox Jewish culture, and its implications for the psychotherapeutic encounter, be expanded and increased, if this population is to be effectively served within the mental health services milieu. (p. 325).

The researcher goes on to state that inasmuch as Jews are often overlooked in ethnocultural literature or training regarding minority groups, Orthodox Jews, who represent only a subsegment of the Jewish population, are often further eclipsed in discussions addressing multicultural issues in treatment. This, even while the values and

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lifestyle of the Orthodox Jewish population are so pervasive across so many aspects of the Orthodox Jewish individual’s areas of daily functioning, that attempts at treatment of this population without an awareness and sensitivity to Orthodox Jewish culture are likely to compromise, or even preclude, successful implementation of clinically effective strategies (Feinberg, 2005; Schnall E. , 2006). Hence, Starck’s study was undertaken with the goal of identifying the attitudes and dynamics which exist in the Orthodox Jewish woman’s psychotherapy treatment.

The research study was a qualitative, exploratory study of 3 Orthodox Jewish women whose presenting problems commonly consisted of depression, anxiety, problems with self-esteem/self-image and interpersonal struggles. All participants received individual psychotherapy and reported on a total of 26 discrete courses of psychotherapeutic treatment which was defined as continuous treatment from one therapist. Treatment duration ranged from several months to 11 years. Data collection was accomplished via in-depth interviews using a standardized semi-structured interview instrument based on Wikler (1989), which aimed at understanding a patient’s private theories of pathology and cure, as well as descriptions of changes during and after therapy. In addition, the participants were asked about their retrospective view on what they felt was beneficial in their treatment.

The qualitative analysis yielded two levels of findings which identified beneficial phenomena that influenced the psychotherapy process and outcome in the context of: (a) the specifically Orthodox Jewish client; and (b) the universal experiences of individual

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patients in psychotherapeutic treatment. Within the first category – factors specifically related to the Orthodox Jewish patient – three curative elements were identified including “psycho-spiritual expertise”, “specific religious identity,” and “gender suitable.”

The first element, “psycho-spiritual expertise,” was defined as having a therapist who offered an “integrated package” of both religio-cultural and clinical expertise. This factor was identified as the most beneficial for these Orthodox participants. Included in this category was the therapist’s ability to talk about and assist with the spiritual component of their problems and incorporated discussions which explored the ability to participate in spiritual pursuits (such as praying and learning Torah) and their relationship with God. The participants reported that being able to locate, explore and examine the spiritual dimension filled an existential gap which they felt was germane to their internal conflict.

“Specific religious identity,” the second identified element, referred to the participant’s preference and experience of working specifically with an Orthodox therapist, which they found highly beneficial to their treatment. Participants reported that their therapist’s intimate knowledge of, and understanding about, the Orthodox Jewish population’s cultural beliefs and practices, and the practitioner’s ability to better appreciate the environmental forces and social dynamics which impinge upon members of this community, allowed them to feel genuinely understood, and connected with the therapist. Being Orthodox Jewish, allowed the therapist to respond with respectful interventions which the participants felt were religion-syntonic. The researcher concluded

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that Orthodox Jews may have an expectation that having a therapist who can understand Orthodox culture will enhance treatment.

The third helpful factor identified in this category was entitled “gender suitable.”

The participants reported that working with a same-gender therapist facilitated easier communication and enhanced quality of the treatment by allowing for a wider scope of topics which they were willing to address. These Orthodox women reported that working with a same-gender therapist avoided discomfort, awkwardness and anxiety around discussion of normative religious sensibilities about the practice of privacy, sexual modesty and yichud (the laws prohibiting seclusion with an opposite gender person who is not a close relation).

The second category – universal experiences of individual patients in psychotherapeutic treatment – included two curative factors reported by the participants, “rapport enabling,” and “highlighting strengths.”

“Rapport enabling” was identified as one of the chief criteria each woman had for deciding whether the work with a given therapist was helpful and included the idea and feeling that the patient had a good rapport with the therapist. The participants used many different terms in characterizing this feeling, although their descriptors all seemed to cluster around two common threads: (a) feeling that they and their therapist were on the same wavelength, such as feeling that she was being heard; feeling that her therapist was responsive, sensitive, perceptive, and conveyed a palpable integrity; and feeling that she could communicate comfortably with her therapist to the extent that she could open up to

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her, (b) being able to feel safe in making disclosures to the therapist, such as feeling that the therapist was validating, non-judgmental, not telegraphing her own personal opinions and beliefs; and that the therapist was compassionate, intuitive, and not overly selfdisclosing.

“Highlighting strengths,” the second identified curative factor, referred to the therapist promoting the patient’s strengths at least as much as they delved into the patient’s weaknesses and deficits and included four main components: 1. pointing out client strengths, such as commenting on the progress a client is making, 2. positive reframing, such as explaining a client weakness or deficit as a once appropriate strength that made sense in an earlier context, 3. attending to strengths embedded in defenses, for example intellectualization allows clear thinking, and 4. interpretation of a strength within one cultural context but not another. The participants felt that by highlighting their strengths the therapist helped to broaden their perspectives, provide hope and motivation, and create positive meanings through reframing and metaphors.

Starck’s research is unlike its predecessors in that it elicits the beneficial aspects of individual psychotherapy from the perspective of the Orthodox Jewish patient and it provides implications for three constituencies: practitioners who might work with this

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population; prospective and current Orthodox Jewish psychotherapy consumers; and the Orthodox community at large, including its leaders and laypersons. Based on the data from this study, the researcher concludes that Orthodox Jewish psychotherapy clients’ religion, culture and identity interact with and color their treatment experiences. The author points to the importance of understanding and being familiar with the basic beliefs, practices, and cultural sensibilities of this population and that failure to take these areas into account during the treatment process may lead to underutilization of services, premature termination, or unsatisfactory outcomes (Sue, 1998).

The above study has several limitations. One potential limitation includes the narrow demographic makeup of the participants who were middle or early-middle age females with advanced college degrees. A study which is more inclusive of male respondents, representing a broader age range and more educational diversity (many Orthodox Jews do not attend college) might facilitate a broader understanding about what might be considered curative in psychotherapy and more representative of the viewpoints of all Orthodox individuals. Another major limitation of the above study was that it was not specifically a psychoanalytic case study. Consequently, it seemed more focused on outcome than process and lacked an in-depth exploration into whether the helpful aspects of treatment were in accord with the interpersonal, intrapsychic, or common factors conception of therapeutic action. The present study utilized a self psychological interpretive lens that makes it more inclusive of psychoanalytic themes and ideas. In this

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way, the participant’s individual treatment narratives were constructed in a manner more in line with psychoanalytic themes.

Chapter Summary In summation, Schnall (2006) in his review describes the literature discussing Orthodox Jewry as meager. The current review comes to a similar conclusion; the literature is sparse and focuses primarily on two areas: introducing therapists to this population and making therapists aware of specific mental health issues this population faces. However, there is literally no literature, save the above study, discussing Orthodox Jews and their experience within the psychotherapy setting. And while this is certainly an anticlimactic ending to the current literature review, it does point to a gap that the current study sought to fill.

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Chapter III Methodology The intent of this phenomenological study was to explore the lived psychotherapy experiences of Orthodox Jewish patients. Specifically, I aimed to identify and gain deeper insight into the particular elements of the therapeutic experience this population found most helpful. The researcher believes that a better understanding of what makes therapy beneficial for this population will allow certain culturally specific adjustments to be implemented, which can better facilitate motivation, treatment compliance, trust, and the establishment of a therapeutic alliance. In seeking to understand this phenomenon the study addressed four research questions: 1. What are the specific beneficial elements of the therapeutic encounter as experienced by Orthodox Jewish patients?

2. What about the therapy process feels helpful to Orthodox Jewish patients?

3. How did one’s Orthodox Jewish identity impact his or her subjective experience of psychotherapy? And, 4. How do Orthodox Jewish patients’ experiences of treatment compare with existing definitions in the current literature?

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The following chapter describes this study’s research methodology and includes discussions around the following areas: 1. rationale for research approach, 2. description of the research sample, 3. summary of information needed, 4. overview of research design, 5. methods of data collection, 6. analysis and synthesis of data, 7. ethical considerations, and 8. issues of trustworthiness.

The chapter culminates with a brief concluding summary.

A Qualitative Approach The value of qualitative research in identifying psychotherapeutic factors from the patients’ perspective has been highlighted by Gordon (2000), who described the lack of such research as a weakness in developing theory and clinical practice. And while a growing number of qualitative studies studying the patient’s perspective have been carried out, as fully described in the previous chapter, these remain relatively few in number compared to the volume of quantitative studies. Moreover, there are virtually no

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qualitative studies exploring this perspective from the Orthodox Jewish patient. Hence, to balance the situation, more studies investigating how Orthodox Jewish patients themselves give meaning to the many aspects of therapeutic change are needed.

Whilst quantitative research has enabled a great deal of progress, it also has limitations (Wertz, et al., 2011). For example, since such research often utilizes hypotheses and structured reporting methods, understanding is limited by its attempts to isolate and manipulate experimental variables, rather than be concerned with talking with patients and exploring how they make sense of their experience (Rowan, 1992).

Additionally, within quantitative research, participants can only comment upon what they are asked to respond to, which may produce a fragmented picture. This is different from qualitative research which emphasizes the need to understand the individual’s experience from within and stems from the philosophical school of hermeneutic-phenomenology (Kazdin, 1998). Although such a process compromises scientific validity, it allows the richness of the human experiences of the individual to be retained in the analysis and interpretation and is therefore particularly appropriate for analyzing the data derived from participants’ personal experiences.

With this in mind and considering how the particular research question of this study may best be addressed, this study adopted a qualitative methodology. Such approaches have the advantage of allowing in-depth and detailed study of phenomena that are not easily quantifiable, as in this study which sought to uncover the “lived experience” of Orthodox Jewish patients. Such subtleties are difficult to measure using a

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quantitative lens. Qualitative methodology whose objective is to extract and interpret the meaning of experience is therefore more suitable and in keeping with this research study.

Rationale for Interpretative Phenomenological Analysis While the natural sciences utilize positivist methods to study phenomena, for the human sciences such an approach is inappropriate. As such, this study, which sought to better understand the subjective experience of Orthodox Jewish patients in treatment, takes a hermeneutic-phenomenological point of view, that is, an interpretive discipline dealing with meanings. Consequently, from a design perspective this study utilized Interpretative Phenomenological Analysis (IPA), as outlined by Smith, Flowers and Larkin (2009).

Grounded in the Husserlian philosophy of understanding a human experience in detail, IPA is committed to the examination of how people make sense of their life experiences (Smith, Flowers, & Larkin, 2009). It is based on phenomenological theory in that it is concerned with exploring a phenomenon – an experience “in its own terms” rather than attempting to reduce it to “predefined or overly abstract categories” (Smith, Flowers, & Larkin, 2009, p. 1). Thus, it is consistent with the research aims. IPA is also interpretative, involving a two-stage interpretation process, or “double hermeneutic” where, as the participants are trying to make sense of their world; the researcher is trying to make sense of the participants trying to make sense of their world. Given the role that

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hermeneutics plays within the model’s paradigm, IPA seeks to uncover and interpret the depth and meaning of individual encounters by helping participants pause, and fully reflect, on their experiences (Smith & Osborn, 2008).

Furthermore, the aim of IPA is not to make premature generalizations about larger populations, but rather to arrive at more general claims cautiously, and only after the painstaking analysis of individual cases (Smith J. A., 2004). That is, IPA is concerned with the particular; revealing something about the experience of each of the individuals involved and being able to say something in detail about the participant group.

According to Smith et al.: IPA is committed to understanding how particular experiential phenomena (an event, process or relationship) have been understood from the perspective of particular people, in a particular context. (Smith, Flowers, & Larkin, 2009, p. 29) As such, IPA is idiographic in nature which is in keeping with the aims of this study that seeks to better understand how those within the Orthodox Jewish culture might view the psychotherapy experience.

Why Not a Different Qualitative Method?

In this section, a rationale is presented for choosing IPA over three other types of qualitative analysis that were considered as possible alternatives: Grounded Theory, Case Studies, and Narrative Analysis.

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IPA was chosen over Grounded Theory even though both approaches are interpretivist, as grounded theory may be considered more of a sociological approach while by contrast IPA is more concerned with giving a more detailed and nuanced account of the personal experiences of a smaller sample (Smith J. A., 2008).

Additionally, while Grounded Theory is an approach for looking systematically at (mostly) qualitative data aiming at the generation of theory, IPA aims “to capture and explore the meanings that participants assign to their experiences” (Reid, Flowers, & Larkin, 2005, p. 20) which was felt to be more in keeping with this study’s aims.

Although methodologically similar to IPA in its focus on informed depth of inquiry rather than breadth, I decided against using a Psychoanalytic Case Study, such as the one originally utilized by Tolleson (1996) and later adapted by Krohn (2016) in which participants’ personal narratives are elicited and understood psychoanalytically. The researcher was concerned that eliciting thought-provoking and personal information regarding family life and childhood history, a necessary component for constructing a case study, might prove too threatening for participants within the Orthodox Jewish community who value discretion and privacy. Consequently, a Psychoanalytic Case Study design was ruled out.

Narrative Analysis was considered as it is also a social constructionist approach concerned with exploring the life story of an individual and combines this with an explicit interest in the social backdrop of the recounted life (Hyden, 1997). Unlike IPA, however, the narrative account is not deconstructed into themes. Researchers accept the

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structure imposed on the story by the narrator and focus on analyzing why the account was structured in that way and how the narrator made sense of their story (Riessman, 1993). This study which seeks to better understand how each participant viewed his or her experience in treatment hopes to produce an ordered and coherent cluster of themes which capture most strongly each respondent’s concerns on this particular topic. As such, IPA is more in line with this study and its objectives.

The Research Sample In keeping with the IPA model whereby “participants are selected on the basis that they can grant us access to a particular perspective on the phenomena under study” (Smith, Flowers, & Larkin, 2009, p. 49), a purposeful sample consisting of four adult Orthodox Jewish participants from the New Jersey area was utilized for this study. This method of sampling selected participants according to the needs of the study (Moustakas, 1994), which involved examining a unique phenomenon – the beneficial aspects of Orthodox Jewish patients’ psychotherapy experience. The sample was homogenous in the sense that all participants identified as Orthodox Jewish. As first suggested by Reid et al.

(2005) less is more in IPA: fewer participants examined at a greater depth is always preferable to a broader and simpler descriptive analysis of many individuals. Moreover, given the overall stigma and shame associated with the Orthodox Jewish psychotherapy patient, the researcher anticipated some level of hesitation and unwillingness on the part of potential participants to come forth and participate in the study. Nevertheless, Smith,

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Flowers and Larkin (p. 52) conclude that “there is no right answer to the question of sample size,” and this study followed their recommendation that it is the number of interviews (i.e., four participants interviewed twice) rather than participants, that are within a suitable range of IPA sample size.

The sample consisted of four Orthodox Jewish individuals who met the following study criteria: •

Self-identified as Orthodox Jewish.

•

18 years of age or older.

•

Actively or previously engaged in either individual or couples counseling (or both).

•

Were/are minimally engaged in weekly treatment for at least six months, and that,

•

Have ended their treatment within two years of the study.

The final two inclusion criteria were added in an attempt to help ensure that participants spent considerable time in their own treatment and could meaningfully reflect upon their experience. Participants who met the criteria were offered to be interviewed by the researcher. Participation was completely voluntary, and only patients who were willing to participate in the study were interviewed.

Respondents were recruited for this study via two avenues. Firstly, distributing a descriptive flyer (Appendix A) to the researcher’s personal contacts (psychotherapists,

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psychiatrists, dentists, and physicians) who reside in the New York and New Jersey area, both of which have a sizable and cohesive Orthodox Jewish population and patient base, to place in their waiting rooms so that Orthodox individuals could learn about the study and self-select themselves for participation. Secondly, hanging the flyer in various synagogues and stores throughout the Lakewood, New Jersey community so that Orthodox individuals could learn about the study and choose whether to participate.

Candidates who expressed interest in participating called the researcher directly and were pre-interviewed via phone (Appendix B) to ascertain whether they met study criteria as well as locational convenience. Four candidates expressed interest in the research, met inclusion criteria, were scheduled for a first interview and followed up with a preliminary phone call, as described in the next section.

Data Collection Methods This study utilized a process of data collection that included a personal interview, preliminary phone-call, an initial one-on-one-interview, member checking, and a second one-on-one interview. Although at times superfluous, such practice, termed ‘triangulation’, ensured that rigor, depth and validity of participant meaning and experience was in keeping with qualitative research (Bloomberg & Volpe, 2012). The various phases evolved as follows:

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Phase I: Personal interview.

According to Creswell, bracketing is most often thought of as a process within the data analysis phase of a study (Creswell, 2007; Giorgi A. , 1997) in which the researcher must “set aside, as far as humanly possible, all preconceived experiences to best understand the experiences of the participants in the study” (Creswell, 1998, p. 235). To achieve such presence, I was the first respondent in this study, personally answering the interview schedule questions by way of writing, in advance of all other respondent interviews. This procedure insured the validity and reliability during this phase of the study and is in keeping with the recommended IPA approach of “suspending preconceptions” (Smith, Flowers, & Larkin, 2009, p. 42). It is important to point out that in this study, I followed the 20th century hermeneutist, Gadamer (1995), who asserts that neutrality or the actual suspending of one’s preconceptions is an impossibility. Rather than the extinction of one’s self, the researcher’s task is to be conscious of hidden prejudices which would otherwise, “make us deaf to what speaks to us in tradition (p.

270).” In this way, I was able to remain open to the meanings of participants, while bearing in mind, that this included situating it with the whole of my own meanings. This hermeneutical task allowed me to analyze and effectively differentiate participant measurements of meaning against my own, or in the words of Gadamer, “thus assert its own truth against one’s own fore-meanings (p. 269).” This mode then, is what is meant whenever the terms “bracketing” or “suspending preconceptions” are mentioned in this study.

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Phase II: Preliminary phone call.

The week before the scheduled interview, a preliminary telephone call was conducted to familiarize participants with the study, answer any questions, and to finalize the time and place for the interview. Participants were asked to spend time thinking about their overall experience as a psychotherapy patient and to review the interview schedule (Appendix E) which was emailed to them a week in advance of the first scheduled interview. By preparing themselves and refreshing their memories of their experiences, participants become that much more co-researchers in the study (Moustakas, 1994) and are offered the opportunity to prepare for the next step, which is in keeping with IPA methodology (Smith, Flowers, & Larkin, 2009).

Phase III: Primary interviews.

Before starting the actual interview, I verbally reviewed the interview procedure and the rights and confidentiality (Appendix C) with the participant. Participants were then instructed to read through the Individual Participant Consent Form (Appendix D) and confirm understanding by verbally reflecting back their understanding of our discussion and the information contained in the consent form.

In this study, the interview questions along with prompts (Appendix E), were organized along seven categories: 1. Demographic Data,

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2. Therapy History, 3. Therapy Expectations, 4. Religious Self-Definition, 5. Therapy Process and Outcome, 6. Perceived Benefits and 7. Closure.

The questions were designed by the researcher to cover issues relating to the experience of psychotherapy from the patients’ perspective, as well as the specific factors which patients deemed most beneficial. Questions were open-ended and moved from the general to more in-depth and specific as per the IPA ‘funneling’ process (Smith, Flowers, & Larkin, 2009, p. 61).

I then conducted initial interviews with each of the four participants, in the setting of their choice, with each interview lasting between 60 and 90 minutes. Notes and memos were taken by the researcher throughout the process and all interviews were digitally recorded and then transcribed by the researcher. Digital recordings, along with transcriptions were stored on my password protected personal computer in a file marked with additional password protection under participants’ pseudonyms. The personal computer was stored behind locked doors.

The primary interviews were semi-structured, the preferred by method of IPA methodology, because respondents are perceived to be the experiential expert on the

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subject thereby allowing the researcher to enter, as far as possible, their psychological and social world (Smith & Osborn, 2008). Additionally, this also allows for the emergence of participants subjective experience and provides the maximum opportunity for them to tell their own story with the least amount of filtration (Giorgi & Giorgi, 2003; Moustakas, 1994)

Phase IV: Member-checking.

Lincoln and Guba (1985) consider member-checking the single most important provision that can be made to bolster a qualitative study’s credibility and maintain the accuracy of data, bracket researcher bias, and assure the quality of findings. Two weeks prior to the scheduled second interview, I emailed participants a copy of his/her documents for review asking them to read the interview transcripts and detailed themes and descriptions of dialogues in which they participated, with an emphasis on whether they considered their words to have been accurately captured, match what they actually intended, and whether the documents adequately and completely described their experience in psychotherapy. In this way, participants voices were completely and satisfactorily included, and member-checking procedures were appropriately addressed.

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Phase V: Secondary interviews.

Multiple interviews with the same participants help enhance the internal reliability of their accounts (Mackey & Gass, 2005) and Smith, Flowers and Larkin (2009) highly recommend second interviews as a means of providing rich information and sufficient opportunities to probe and elaborate the data. After transcribing, analyzing and discussing the first round of interviews and its data with my chair and research committee, I then conducted the second round of one-on-one interviews with each of the participants, in the setting of their choice. These interviews lasted between 60 and 90 minutes and provided me the opportunity to explore additional thoughts and questions that occurred upon participant reflection and member-checking and clarify aspects of the previous interview.

Providing time between interviews allowed for adequate participant reflection and contemplation and the second interview occurred approximately a month after the initial round. Respondents read through the initial interview transcript again, made some minor word adjusting, and communicated that they had exhausted the entirety of their ideas during the initial interviews. These second interviews therefore primarily served to ensure the validity of the data gained in the primary interviews, inform the ongoing process with all respondents and ultimately served to positively impact my understanding of a respondent’s experience as time passed.

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Methods for Data Analysis & Synthesis In IPA methodology, the analysis of transcripts and data utilizes a reflective engagement with the participants account. That is, a hermeneutic turn between the researchers theoretical knowledge and the data, or “an account of how the analyst thinks the participant is thinking,” (Smith, Flowers, & Larkin, 2009, p. 80) effectively exercising a double hermeneutic. Thus, the procedure which comprises the data analysis in IPA is live, dynamic and systematic rather than a static “scholarly collection of ideas” (p. 33). The researcher works through different levels of analysis that include exploring, describing, interpreting and situating the means by which respondents make sense of their experiences. These must always be rooted in IPA’s overriding principle of “meeting of the researcher and the text” of the data (p. 34) for it to eventually reach deeper levels of analysis. So that, successful analysis with IPA requires not only a systematic application of ideas, but also a combination of reflective, critical and conceptual thinking (Smith, Flowers, & Larkin, 2009) and a constant attempt to get behind the eyes of the participant, so that the analysis is a joint product of the participant and the analyst. The data analysis in this phenomenological study was highly structured and detailed and developed into the following six-step approach which led to substantial analysis as detailed and expanded upon below.

1. reading and re-reading 2. initial noting

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3. developing emergent themes 4. searching for connections across emergent themes 5. moving to the next case 6. looking for patterns across cases (pp. 82-107).

The first two steps of analysis involved getting closer to the original transcript data from each participant through a reading and re-reading of the text as well as listening and re-listening to the original recordings of each individual interview. This iterative process enabled the discovery of new information not noted in the initial reading and allowed me to develop new insights and re-familiarize myself with each individual interview process (Smith, Flowers, & Larkin, 2009; Bloomberg & Volpe, 2012). As the transcript was read, I used the left-handed margin to annotate anything I found interesting or significant about what the respondent said.

After the careful review of material I began recording notes in the right margin of the transcript, logging anything of interest relevant to the respondents’ experience being studied. This corresponds to the second stage of data analysis termed “initial noting” whereby exploratory comments take the form of descriptive, linguistic, and conceptual analysis (Smith, Flowers, & Larkin, 2009, p. 83). Descriptive comments rephrase and describe the content of the participant’s account (p. 84). Linguistic comments include paying attention to and exploring the language that the participant used; (p. 81) and conceptual comments involve focusing on “engaging at a more interrogative and

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conceptual level” (p. 81) and include my knowledge from the literature and life experience. For each interview text, I created a three-column table with the original data placed in the middle column; the three kinds of comments written in the last column; and the first column was left empty for the next step.

In the third step, I took a more central role in the organization and analyzation of the data, by identifying emergent themes based on the three types of comments from the previous steps. According to Smith, Flowers, and Larkin (2009) themes should “reflect a synergistic process of description and interpretation in that they not only reflect the participants original words and thoughts but also the analyst’s interpretation,” and are “usually expressed as phrases which speak to the psychological essence of the piece and contain enough particularity to be grounded and enough abstraction to be conceptual (Smith, Flowers, & Larkin, 2009, p. 180).” Focusing on discrete chunks of transcript, while simultaneously, recalling what was learned through the whole process of initial noting, maintained the hermeneutic circle, so that the part was interpreted in relation to the whole, and the whole interpreted in relation to the part (Pietkiewicz & Smith, 2014).

The fourth stage of analysis made sense of the connections and patterns across emergent themes. This entailed listing themes chronologically and moving them around to form clusters of related themes. To accomplish this, I wrote the themes in chronological order on a master list, and then to best determine how they related to each other, each theme was individually printed on a separate piece of paper and placed on a large table. In this way, the themes were represented spatially, as per IPA (Smith,

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Flowers, & Larkin, 2009, p. 96). Using IPA’s conceptual tools of abstraction and subsumption, I then searched for themes with parallel understandings, placing them together, while opposing themes were placed at opposite ends of the table. I constantly sought to cluster the themes in order to identify and develop superordinate themes which best described the conceptual characteristics of the clustered themes. During the entire clustering process, I constantly referred back to the transcript to make sure the connections worked for the primary source material, that is, the actual words of the participants. Those which I was unable to thoroughly substantiate were discarded. In this way, I was constantly checking my own sense-making against what the person actually said, in keeping with IPA’s iterative nature (Smith, Flowers & Larkin, 2009). Once I felt the descriptive process had been exhausted, I created a table representing the structure and development of the superordinate and subthemes of the data (Smith, Flowers & Larkin, 2009).

In the fifth step of the data analysis, I repeated the previous four steps for the other participants one by one, systematically following what had been done for the first participant, in an attempt to understand each participant’s unique experience of the phenomenon. This ensured that each case was treated on its own terms, allowing for new themes to emerge and to do justice to its individuality (Smith, Flowers, & Larkin, 2009, p. 100). Individual tables were completed and recorded for every transcription.

In the final stage of the data analysis I searched for patterns across the four cases.

Specifically, I laid out each table and examined their connections to best determine how a

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theme in one case illuminated another case and which themes were most potent using the fixed superordinate themes across all core cases as the boundaries for commonalities and divergences. The IPA conceptual tool of numeration was used to measure the frequency with which a theme was supported or prevalent in most of the cases. These were then clustered into master themes representing shared higher-order qualities. In line with IPA’s cyclical approach whereby one looks simultaneously to the whole to understand each moving part and to the parts in order to understand the whole (Smith, Flowers & Larkin, 2009), I organized different cases under the same superordinate themes to allow each case (the part) to be connected with each other, contributing to shaping a united theme structure (the whole). Continuously relabeling and reconfiguring themes finally resulted in a master table of superordinate themes for the entire group (Smith, Flowers & Larkin) which prepared me for writing the report on the findings.

It is important to mention, that my being a member of the population being studied and ‘insider status’ (Smith, Flowers, & Larkin, 2009), posed a threat to data validity. To counter this, I continuously collaborated with my research committee and dissertation chair throughout the process of data collection and analysis. This not only ensured an objective, well-balanced perspective of data interpretation and respondent offerings, but also served to bracket out my personal experiences and subjective understandings of the phenomenon. In this way, the validity of the data was effectively maintained.

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Ethical Considerations This study employed various safeguards to ensure the protection and rights of its participants, as ethical issues relating to protection of the participants are of vital concern (Marshall & Rossman, 2011). Firstly, all participants were volunteers. Though there was no anticipated physical risk in this study, there existed a potential for emotional distress.

To minimize this potential, the researcher, an experienced clinician, screened for emotional vulnerability, disqualifying any volunteer who displayed a propensity to react with severe emotional response to participating in this study. Secondly, all participants were informed that they had the option to suspend, delay, or end the interview at any time. Participants were also informed that they could opt out of discussing aspects of their therapeutic experiences and lives that felt too distressing. Thirdly, the researcher checked in at specific periods during the interview to ask participants how they are doing and if they felt capable of continuing. Signs of tearfulness, expressions of anger or irritability, loss of focus, withdrawal and changes in tone or affect were all considered possible reactions alerting the researcher to interrupt the interview and to evaluate levels of emotional distress and discomfort. Additional protections for the participants included a debriefing section at the close of the interview to provide additional opportunities for processing the interview experience. Further, participants were provided with the telephone number of the researcher/clinician and encouraged to contact or consult with the researcher regarding any emotional reactions resulting from the study. An appropriate referral to a competent clinician would be made. While this study did not provide any

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direct benefit to the participants, it was considered to be work that would greatly benefit the Orthodox Jewish community of which all participants will be a part.

Participants were fully informed about confidentiality and throughout the study measures were taken at every juncture to ensure that the identities of the participants be fully and indefinitely protected. These measures include conducting the interviews in private settings; having the investigator himself transcribe the interviews; and using pseudonyms for all participant names in the transcripts. Furthermore, participants were made aware that although quotes would be used in the write-up for the study, all identifying information about themselves will be removed from the transcripts and writeup and that members from my dissertation committee would only look at the pseudonymized transcripts.

Issues of Trustworthiness Patton (2001) speaks of the need for qualitative and quantitative researchers to test and demonstrate that their studies are credible. While validity and reliability in quantitative studies are established through rigorous removal of researcher and methodological bias in the research instruments, credibility, the equivalent in qualitative studies of validity and reliability (Patton, 2001), seeks to test the validity of conclusions reached and is established through rigorous attention to bias in both methodological and interpretive validity (Bloomberg & Volpe, 2012). Methodological credibility is defined as

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the interrelationship between the method’s logic and the formulated research questions as well as the kind of explanation the researcher is attempting to develop, while the quality and rigor with which the researcher interprets and analyzes the data in relation to the research design defines its interpretive validity (Bloomberg and Volpe, 2012). And while there are a number of available guidelines for assessing the quality of qualitative research (Elliott, Fischer, & Rennie, 1999), this researcher conformed with entrusted IPA protocols by following Smith et al. (2009) who recommend adhering to Yardley’s (2000) four principles and how they apply to an IPA study. This includes: 1. Sensitivity to context – demonstrating sensitivity to the existing literature and theory, the socio-cultural setting of the study (Yardley, 2008) and the material obtained from the participants (Smith et al. 2009). These aspects were demonstrated through the comprehensive theory and literature review included in Chapters I and II which relate the study to other relevant research and theory; by placing participants and the researcher in context through a description of demographic and other relevant background details and discussing how these factors have shaped the participant reports in Chapter V. Finally, sensitivity to the data was maintained through conducting and describing an in-depth analysis and supporting my arguments with verbatim extracts, thereby providing a “voice” for participants in the project and allowing the reader to check the interpretations being made (Smith et al.

2009).

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2. Commitment and rigor – described by Yardley as the commitment to in-depth engagement with the topic and through developing competence and skill to ensure thorough data collection and the depth and breadth of analysis. Smith et al. (2009) suggest that this may be demonstrated through attentiveness to participants during data collection and taking care over the analysis, which was accomplished through the triangulation of perspectives on the same data set (Bloomberg & Volpe, 2012), by bracketing my personal experiences and subjective understandings of the phenomenon, and by reviewing and discussing the data collection with my dissertation chair and research panel.

3. Transparency and coherence – Smith et al. (2009) state that transparency refers to how clearly the stages of the research process are described in the write-up, and that there should be coherence between the research that has been carried out and the underlying theoretical assumptions of the approach being utilized. To this end, all aspects of this study including the research questions, design, data analysis, and researcher assumptions, biases, interpretations and findings were kept as transparent as possible and in the preceding paragraph I detailed every aspect of the processes of data collection and analysis and research process. Yardley also includes consideration of reflexivity, or “reflecting on the impact of the researcher on the research process,” within the principle of transparency. A discussion of my acknowledged personal biases will be presented in the following section.

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4. Impact and importance – This final principle states that the most decisive way a research study may be evaluated is in whether or not it tells the reader something interesting and useful. To this end I included a consideration of the clinical relevance of this study in treating the Orthodox Jewish population and the ways in which it might contribute to the literature in Chapter VI, the Conclusion section, below.

Reflexivity – The Role & Background of the Researcher Elliott et al. (1999) talk about the importance within qualitative research for the researcher to “own one’s perspective” since it is acknowledged that the beliefs and assumptions of the researcher will influence how they collect and analyze the data. The following section therefore comprises a personal statement, written with the aim of being as clear as possible about what these beliefs and assumptions are.

All interviews were conducted by this study investigator, himself an Orthodox Jewish, Ashkenazic, “frum-from-birth” (FFB)1 American man in his 40s. I grew up in Brooklyn, New York within a densely populated Orthodox Jewish community, and

1

Frum-from-birth or FFB refers to an individual who was born and raised in an Orthodox family. This is in contradistinction to the Baal Teshuvah or BT (returnee to Judaism), a formerly non-observant Jew who has become observant of traditional Jewish religious law as practiced in normative Orthodox Judaism.

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attended Ultra-Orthodox schools my entire life. After graduating high school, I continued on with my Jewish studies, studying at Rabbinical colleges in Pennsylvania, New York, Israel, and finally New Jersey for a total of fifteen years. I received Rabbinical ordination in several areas of Jewish law, including the laws of family purity and dietary laws, lectured in various communities throughout the United States, and I am intimately familiar with Orthodox Jewish life, culture, tradition, custom, philosophy and language. I currently reside in Lakewood, New Jersey which is home to close to 60,000 highly religious Orthodox Jews.

I then decided to pursue my professional career and have worked in the field of mental health since 2009, and in the last three years within the Orthodox Jewish community. I am currently the clinical director of an agency in Lakewood, New Jersey whose patient base is exclusively Orthodox Jewish, and have a private practice where I treat members of the highly religious Lakewood community. I trained at the Institute for Clinical Social Work since 2012, enhancing my clinical knowledge and skill-set in psychodynamic theory and practice.

My epistemological stance can be best described as modernistic. My religious upbringing and personal journey very strongly reject the post-modern notion that no one has the authority to define truth or impose upon others his idea of moral right and wrong.

My lived experience as an Orthodox Jew, has fully shaped my belief in the supremacy of Torah and its being the manifestation of God’s word. Consequently, I do believe there is an Arbitrator of truth, reality, right and wrong, a direct result of my cultural upbringing,

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personal journey and my religious self. Nevertheless, in line with Gadamer’s notion of hermeneutic objectivity, when dealing with and trying to understand the other, I try to be aware of my projections and my particular expectations and constantly strive to be open to working these out and by allowing these to revise my understanding. When dealing with others then, I am thus open to post-modernistic views, specifically to the idea that people construe meanings from their experiences based on their particular cognitive maturity, exposure to the social context, the psychodynamics operating at the time of their exposure to events, and that for some, absolute ‘truths’ do not exist. In this way, I hope that the other’s perspective side by side with my prejudices and biases, result in the full potential of my understanding.

In terms of theoretical orientation, I readily acknowledge the influence self psychology has had on my thinking and practice. As such, I believe in the effect of external relationships and how this helps maintain self-esteem and self-cohesion. In line with the self psychological view, I believe that the pathogenesis and cure of patients’ problems stem and derive from a struggle with a deficient self and having needs that must be understood and partially met in the treatment and/or within other settings. With the psychotherapy patient in particular, I see them as being in desperate need of certain responses from the therapist to maintain a sense of well-being.

I underwent my own therapy for several years and am cognizant of how the psychotherapy experience is, by its nature, a very private, intimate, and singular experience. As an Orthodox Jew, I grew up in a family (reflective of the larger culture)

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where to have a problem that might require professional help was viewed as a personal weakness and unnecessary. At that time, I too worried about stigma, as well as the fallout-effects on family image and marriage prospects, and it took me a long while to be comfortable with the idea of psychotherapeutic treatment. I recall taking my first steps into the therapy process and having only a limited understanding of what it entails. The associated feelings were one of being overwhelmed and frustrated at not knowing what to expect, what the full gamut of its prospective risks and gains may be, and how I, as a patient, might be able to play a role in optimizing outcomes. This led to several unsuccessful psychotherapy experiences and as a result, my interest in granting the Orthodox Jewish community – layman and professional – a close-up and in-depth window into the actual landscape of the experience of their co-religionists in therapy was influential in my later decision to pursue a career as a psychotherapist. Since that time, I have retained an interest in increasing the readiness of Orthodox Jews to accept help from the mental health profession as well as increasing the awareness of those who treat them by bringing to light what this population might find is most beneficial. Hence, my decision to develop the current study.

Chapter Summary This chapter discussed the rationale behind this study’s qualitative phenomenological design, and specific use of IPA. It also presented the methodology step-by-step including how the research sample was obtained along with inclusion

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criteria. The phases of data collection were thoroughly detailed as were the stages of data analysis; per IPA. The chapter concluded with a discussion pertaining to ethical considerations issues of trustworthiness and a brief personal statement about the researcher.

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Chapter IV Findings The purpose of this phenomenological study was to understand the lived psychotherapy experience from the perspective of the Orthodox Jewish patient. In this way, I sought to uncover the particular elements of the therapeutic encounter that this population finds most helpful, as well as to examine the subjective attitudes and dynamics that inhere the Orthodox Jewish patient’s treatment experience. The research questions this study sought to answer are: 1. What are the specific beneficial elements of the therapeutic encounter as experienced by Orthodox Jewish patients?

2. What about the therapy process feels helpful to Orthodox Jewish patients?

3. How did one’s Orthodox Jewish identity impact his or her subjective experience of psychotherapy?

4. How do Orthodox Jewish patients’ experiences of treatment compare with existing definitions in the current literature?

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This chapter presents the key findings obtained from eight in-depth interviews including its superordinate and subordinate themes and the analytically derived “essence� of each of these themes.

Introduction to Participants Using Interpretative Phenomenological Analysis (Smith, Flowers, & Larkin, 2009), four participants; two males and two females, located in New Jersey were interviewed. All participants for this study were Caucasian men and women of the Jewish faith who grew up and currently reside within Ultra-Orthodox Jewish communities. The participants self-identified as Ultra-Orthodox and were referred to the researcher, through fliers (Appendix A), which explained the purpose of the research study. The participants indicated they were prepared to be interviewed and discuss the beneficial elements of their respective therapeutic experiences. All participants were interviewed twice.

Interviews were digitally recorded and for purposes of the data analysis, I used both transcriptions of interviews. Assigned pseudonyms names were participant-chosen to protect confidentiality and a brief introduction of each participant follows. The description for each participant includes age, gender, marital and parental statuses, selfdescribed religious orientation, current employment, past and current psychotherapy experiences as well as reason for volunteering.

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Sara.

Sara is an American-born, 36-year-old woman residing with her husband of seventeen years within a well-known Ultra-Orthodox community in New Jersey. They have eight children, sons and daughters, who are of elementary and high school age. Sara has a high school education, and currently works about 35 hours per week as a secretary for a local Jewish organization. She describes her religious identity and upbringing as Ultra-Orthodox.

Sara initially became involved with psychotherapy about five years ago, when she sought help for one of her children who was struggling in school. At some point, Sara decided that it would be beneficial to her family’s overall functioning and well-being if she were to address some of her own difficulties, in the hope that there would be a discernible trickle-down benefit. Thus, Sara engaged the services of a female Orthodox therapist in private practice and began her own therapy. At the time of her interview Sara was seeing her therapist on a weekly, open-ended basis, and had been her patient for the past two years. The major focus of her treatment are self-esteem and self-view. Sara’s husband was initially resistant to the idea of her entering treatment but was more amenable after his meeting the therapist. Since that time, he has had minimal contact with her therapist, but every so often Sara reports back to her husband on progress and developments. Sara volunteered to participate in this research project because she believes “it’s a very important topic.”

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She states: I think it’s very important that people recognize that, first of all, the need for therapy is there; and secondly, it can be a very helpful option. By coming forward, I am hoping that my experience can in some way reduce the negative view the Ultra-Orthodox community holds towards needing and attending psychotherapy and am willing to use my own experience as a means of helping others. (Sara)

Rivka.

Rivka is a 25-year-old, single, never-married Orthodox Jewish woman born and raised in an Ultra-Orthodox family, in Brooklyn, New York. She resided with her parents up until several years ago, when due to a job offer, Rivka relocated to New Jersey, where she currently resides by herself. She self-identifies as Ultra-Orthodox but doesn’t consider herself as yeshivish as those in her current New Jersey community.

I’m not Yeshivish Black Hat, but I’m like Brooklyn Ultra-Orthodox; because I think I’m a little bit broader than Yeshivish Black Hat, but I’m definitely not Modern Orthodox. (Rivka) At age 19, Rivka attended college and currently works at a local pediatrician’s office as a registered nurse. At the time of her interview she had been in weekly therapy for almost two years with an Orthodox Jewish female therapist. She describes her

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presenting problem as depression, emanating from familial conflict and the challenges of being an older single. Specific areas being addressed in therapy include “figuring out what I’m doing with my life, dating and spiritual issues.” Because she is in the medical field, Rivka is open to pharmacotherapy and at the suggestion of her therapist takes an anti-depressant prescribed by her doctor. Prior to entering therapy, Rivka attempted to address her issues “through self-introspection, trying to connect with my feelings and needs by reading psychology books and by talking to trusted teachers and friends.” When asked about what made her volunteer for this research project, Rivka responded: When I saw the flier for this study, I jumped on it. I want people within our community to know that therapy with the right therapist can be so amazing and that they don’t have to struggle alone. It can work. It really works!

Yitzchak.

Yitzchak is a 25-year-old male who self-identifies as Ultra-Orthodox. Dressed like a typical Ultra-Orthodox man, Yitzchak married at age 22, and divorced two years later. He has no children. Presently, Yitzchak lives with his parents in New Jersey where he spends half a day studying at a Rabbinical college and working part-time as a driver for a local Jewish car service company. He never attended college and stopped all secular studies in the 9th grade. During his engagement period, Yitzchak began individual therapy with an Orthodox Jewish male therapist in private practice, with treatment focusing on

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marital skills. After his divorce, he continued treatment with the same therapist and for the past year has attended weekly, individual psychotherapy. He describes his therapist as “exploratory and deep” and his current challenges include issues related to relationships and sexual orientation. He states: To be honest, at times I find myself attracted to men and I am trying to figure myself out, how this might have impacted my marriage and what this means for my future.

When questioned about what made him volunteer for this study, Yitzchak explained: For just about my entire life, my thoughts and feelings were under wrap – you know what I mean? It’s like there was so much there, building up inside me and baruch Hashem [thank God] I’ve been given an opportunity to let it all out – speak it out – but even more, to actually get in touch with it. Kind of like finally being able to peel a cover off an unlabeled can and finally get to see what food is inside. And I know other people in the community must be struggling with the same experience and I just want them to know there can be a light, a way of feeling better – even if it means coming face to face with things that are scary. It, therapy that is, works for me, so why shouldn’t people be aware of it and make it work for them as well?

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Yaakov.

Yaakov is a 52-year-old male, married for close to 30 years and has several married children of his own. A Rabbi by profession, he spends his days learning and lecturing at a Rabbinical college for young men. Yaakov is a respected member of his community and has already authored two books on Jewish law. He reports beginning therapy about a year and a half ago, after issues with one of his married children and their spouse became “intolerable.” He was advised by his Rabbi to seek professional help after nothing seemed to work and reports that what began as a short-term idea has turned into weekly treatment. He currently attends treatment by himself with an Ultra-Orthodox male therapist, and occasionally his wife joins the sessions. When asked about his motives for volunteering he states: To tell you the truth I am pleasantly shocked that it lasted this long and if I had the opportunity I would want the people, the Torah community, to know that with the right person and proper hashkofos [ideology], therapy is not only not bittul Torah [a waste of time that can be better spent studying God’s word] but can serve as a way to better one’s middos [character/traits]. And that’s why I came to you, that’s why I volunteered for this zach [thing]. I view participating in this interview as a big mitzvah [good deed] and my personal achrahyus [responsibility].

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Presentation of Findings The following section used the six-step analytic process mentioned in Chapter III and presents the results obtained from the analyses of eight comprehensive 60-90-minute interviews of the four participants. The data was organized into four superordinate themes and sixteen subordinate themes through the process of reading and re-reading, initial noting, developing emergent themes, searching for connections across emergent themes, moving to the next case and looking for patterns across cases. A summary of these can be found below in Table 1.

According to Smith, Flowers and Larkin (2009) subordinate themes emerge as a structure from the clustering of individual emerging themes and allows the researcher to highlight and extract all of the most interesting and important aspects of the participant’s account (p. 96). The conceptual characteristics of the subordinate themes in each cluster are expressed by descriptive labels known as superordinate themes which are representative of higher order concepts shared by each case (p. 101). In accordance with qualitative phenomenological research (Creswell, 2014) each description of the superordinate theme contains a psychoanalytically acquired “essence,” or an amalgamation of the researcher’s interpretation of the raw data and actual participant excerpts, the ‘I’ and ‘P’ in IPA (Smith, Flowers, & Larkin, 2009).

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Table 1: Summary of Findings Superordinate and Subordinate Themes 1. Orthodox Cultural Touchstones 1.1 Orthodox Jewish Weltanschauung (Pervasive Beliefs and Practices of Daily Living) 1.2 Halachic and Hashkafic (Religious Ideological) Considerations 1.3 Religio-Cultural Inevitability 1.4 The Role of Stigma 2. Orthodox-Syntonic Treatment Process 2.1 Religious Paraphernalia/Symbolism 2.2 Therapist Attire and Self-Presentation 2.3 Transference 2.4 Sense of Privacy and Confidentiality 3. The Therapeutic Relationship 3.1 Empathy 3.2 Sense of Equality 3.3 Going the Extra Distance 4. The Therapeutic Factors 4.1 Self-Understanding 4.2 Psycho-Spiritual Integration 4.3 Psychoeducation 4.4 Highlighting Strengths 4.5 Climate of Hope

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Superordinate theme #1: Orthodox cultural touchstones.

This superordinate theme is titled Orthodox Cultural Touchstones and embodies the normative instances of internal conflict or tension which the Orthodox patient may encounter in the day-to-day course of maintaining adherence to their religious practices and principles, with particular relevance to the psychotherapy encounter.

The beliefs and practices of the typical Orthodox Jew are woven into the very warp and woof of their daily lives. This can make it difficult, if not counterproductive, for them to compartmentalize away their Orthodoxy when in treatment, where they are discussing and exploring the intimacies of their lives. Further, religio-cultural elements play a real and ongoing role in each participants decision to seek and remain in treatment.

This superordinate theme answers the research question: How did one’s Orthodox Jewish identity impact his or her subjective experience of psychotherapy?

The four subordinate themes under this heading are: 1. Orthodox Jewish Weltanschauung (Pervasive Beliefs and Practices of Daily Living) 2. Halachic and Hashkafic (Religious Ideological) Considerations 3. Religio-Cultural Inevitability 4. The Role of Stigma

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The psychoanalytically derived ‘essence’ of this theme recognizes that: for Orthodox Jews, Judaism is part of the very fiber of their everyday lives and cannot be separated from the whole person.

1.1 Orthodox Jewish Weltanschauung (Pervasive beliefs and practices of daily living).

This subordinate theme contains participant accounts of what it means to be an Orthodox Jew, the role this plays on their personhood and how different internalized religion-based concepts and practices (e.g., kashrus, tznius, prayer, lashon hara) impact their daily lives as Orthodox Jews.

For me, religion is my being; you can’t really differentiate it, it’s a way of life, you know what I mean? It’s just not a separate thing. It’s the whole person and a second to second moment to moment way of existing. This is not something which we are actually taught in school or learn about in a class, we just grow up like this. Our parents live it, our friends and relatives and we just do and as I grew older, I became more and more aware of it. It’s not just a hergish [feeling], it’s more than that. That’s just how it is, I can’t explain it any better than that, you know? (Sara)

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I don’t think I went into the therapy room thinking, “Well I’m leaving my religious beliefs and practices outside the door, or I’m going to make some sort of compromise if I do this therapy.” Cause’ they don’t leave me. They’re my way of life, and so they’re always present… In my mind it’s not like ‘I’m Rivka and I’m a Jew’, not like two separate identities or something like that – it’s one and the same, together. Whether I’m in the office working, the kitchen baking, going grocery shopping, in therapy, or when in shul [synagogue] it is who I am and how I live my life and it defines me and how I live my life. Therapy is no different, in fact I specifically wanted to make sure this wouldn’t be a problem I didn’t want to have to start explaining to my therapist the way I had to do when in school to my professors and classmates – because it’s just not something you can give over or appreciate unless you’re a frum [religious] Jew. (Rivka) No doubt about it, Yiddishkeit, Torah and mitzvos, mesorah [tradition] is a part of me it’s who I am, my growth, you know my metzius [very being and existence] …

My bitachon [faith] and emunah [belief] have gotten me through so much and at the same time for my personal situation and nisoyan [challenges] it’s hard for me.

But that’s what it means to be frum [religious], you know, who says it’s supposed to be easy? Me’heicha tei’see [who says] …? If anything, I think I’ve gotten more shtarck [devoted] in my emunah with therapy it’s not a s’tira [contradiction] for me, even if I’m not going to like the maskanas ha’davar [final outcome].

(Yitzchak)

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For me it’s poshut [straightforward] to me. The halachos [Jewish laws], living according to Shulchan Aruch [Code of Jewish Law] that’s my definition of being frum [religious]. From waking up in the morning, to putting on and tying shoelaces – all al pi halacha [in accordance with Jewish Law]. That’s how it’s always been. With age it’s become clearer and clearer. Mussar [books dealing with character development] really working it into your bones your guf [body/being] … Therapy is an extension of this for me, Shulchan Aruch, Mesillas Yesharim doesn’t cease to exist when I’m there, you know. Whatever is discussed is filtered through this daas [knowledge/consciousness] – this was never a shailah [question] by me – therapy discussions have helped me on a deeper level on my thinking and insight into actions. Learning Mussar is more teef [deep] than ever, being aware of my thoughts and kavanos [intentions] more frequently than before – it’s a whole new cheftza [concept/paradigm] of growth for me. (Yaakov)

1.2 Halachic and hashkafic (religious ideological) considerations.

This subordinate theme discusses the importance various Jewish, ideological concepts, cultural norms and religion-based practices has for the Orthodox Jewish patient and its impact on the therapy experience. Specifically, the Orthodox Jewish patient may be conflicted between the culturally based opposing forces of needing to introduce and discuss certain topics, and a hesitation to examine and talk about such topics out of fear, shame or worry.

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Well, I need to feel comfortable talking about issues and practices relating to Yiddishkeit [Judaism]. As a Jewish woman, specifically the mitzvah of Taharas Hamishpachah [Laws of Family Purity] other topics that pertain to women and family life, I need a therapist familiar with these halachos [Jewish guidelines/laws]. Also, my husband sits and learns, it is extremely important to me that I could talk openly about this with someone who gets it, you know, and appreciates the value and great z’chus [merit] this is. I’ve had two friends who went to therapists out of the community and the feeling they got when talking about their husband’s preference to spend many hours sitting and learning Torah for a living, was the therapist’s reaction of disregard for this value. That would be absolutely terrible if I had to go to therapy and couldn’t discuss certain topics that play a major role in my daily living and beliefs, couldn’t discuss it comfortably and without feeling misunderstood or judged or laughed at. (Sara) I went back and forth for a long time – thinking, thinking – about which therapist to go to. There was a highly recommended man, supposed to be a great therapist… but I couldn’t shake the discomfort and awkwardness in being alone with a man therapist and the issur of Yichud [prohibition against being secluded with an opposite-gender individual who is not an immediate relative]. I mean, even if it wasn’t technically ossur [forbidden], as a single girl, I think I would have constantly worried about it and whether or not what I was doing was truly yichud. If I’d be married maybe it would be different, I don’t know, but at the end

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of the day the idea of sitting for an hour alone with a man every week, talking about private things and stuff would be really awkward and uncomfortable. For me at least. (Rivka) Chillul Hashem [publicly disgracing/dishonoring G-d by acting in an unbefitting way] is on my mind all the time. It’s not just with a goyish [non-Jewish] therapist or person, that, that would be the case, but even with a Yiddisha [Jewish] therapist, in my own therapy, it’s something I keep in mind… Like, I’m hesitating to speak ill of certain yeshiva’s [Jewish schools] and Rebbeim [Jewish teachers] and how they act or what they’ve done, it’s not just loshon horah [prohibited speech, gossip] which it is, or maybe in therapy there’s a heter [permissible dispensation], but I still worry such behaviors by a Yiddisha person is creating a situation of chillul Hashem even to a frum therapist. So, it’s like a part of me, is always uh, alert to these things… Me’idch gisa [conversely], though, there are so many kiddush Hashem [sanctification of God] that I feel is created in our discussions about people in the community and how they act and behave.

(Yitzchak) For me lashon hara [prohibited speech such as gossip or slander], was and continues to be a big one and source of anxiety. I mean, it’s gotten better over time, but to this day I still find it very hard talking and discussing people negatively or badly. Especially those discussions which deal with my parents, my growing up years and Rebbitzin [my wife] and my family. On the one hand I

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know that it’s a necessary part of my mental well-being you know, to be able to express feelings and thoughts about certain people in my life, its mutar al pi halachah [permissible by Jewish law] for refuah (medicinal/healing purposes), but at the same time, its mamesh [truly] a struggle when I feel like I am being oiver [transgressing] the issur [prohibition] of lashon harah. He – my therapist is aware of this and has a lot of experience with this – me and him one time looked at the seforim [literature] on the subject and came to a maskanah [final decision] that its mutar [permissible] for therapy purposes. But it’s a constant struggle – not easy. Especially I worry about my therapist knowing other members of the community I talk about and whether that’s a form of lifnei iever [stumbling block]. (Yaakov)

1.3 Religio-cultural inevitability.

This subordinate theme discusses the prominence which Orthodox Jewish patients’ religio-cultural background plays in the actual content and discussion of treatment despite the original, seemingly unrelated, nature of the presenting problem to religion and its concepts.

It’s kind of interesting really, I mean when I came into treatment, I knew very clearly what issues I wanted help with. My low self-esteem and how I viewed myself and things like that, really nothing to do with yiddishkeit [Judaism] and anything related. Yet, thinking back, as time went on more and more my sessions

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and discussions presented quite often. Things like kashrus [dietary laws] and Taharas Hamishpachah [family purity], the Torah view on chinuch [raising children], and quite honestly my own tendency for citing Torah thoughts and teachings became a natural part of our weekly session. Hmm, not sure what to make of that (smiling). (Sara) I never viewed my therapist as my Rebbitzen [female rabbinic mentor]. So, no, it didn’t happen right away. And that’s even though I know that Torah encompasses everything about our lives but somehow, I never went in thinking that it would or even should play a role in my therapy. But I guess I was ignorant, because discussions about Hashem [God] and various mitzvos [commandments] and Mussar vertlach [thoughts on self-improvement] do come up in session, which is what I like. Not right away I think. It took some time, it did, like a month in a half into the sessions or something like that… Guess I needed time to trust her, get to know her, and we discuss hashkofa [Jewish philosophy] as it comes to being an older single and stuff like that. Or maybe it just emerged more natural, you know?

Not a 100% certain about this. But at the end of the day, bottom line is that its relevant to my challenges, but for some reason I just never thought of therapy in that way. (Rivka) He, my therapist is not so yeshivish [Ultra-Orthodox] looking, you know, colored shirts, no beard, you know. Of course, he’s a frum [religious], shomer Shabbos [Sabbath observant] guy, who is quite knowledgeable of halachah [Jewish law]

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and haskafah [Jewish ideology], but just not yeshivish looking… I remember when I originally was looking for a therapist, there was something about me not wanting a real yeshivish looking therapist, and I was even thinking of not looking for someone local because of some of the issues I needed to discuss. I think I was hoping that doing so would avoid talking about yiddishkeit [Judaism] and such topics and just focus on therapy… And for a while that’s really how it went.

There was a long period of exploring things related to marriage, techniques, and just a better understanding of relationships especially of how women think and their needs in a marriage. It’s hard for me to locate when, but at a certain point in time in my therapy, it was like natural, like you know, it became part of our discussion. I am not talking about a mussar schmooze [ethical preaching] or something you might have with a mashgiach [spiritual advisor] but it is kind of like another part that is important to talk about at certain times and according to the conversation, you know what I mean? Like, certain areas of avodas Hashem [service of God], and especially trying to come to terms with and trying to make some sense of my tafkid [life’s purpose], what the Eibeshter [God] might be wanting from me. At times, I will find myself listening to a shiur [Jewish lecture] or reading a sefer [Jewish book] and coming across a thought that really hits me, you know relates to me and I’ll go in and share it with my therapist. We discuss it and it becomes part of my therapy. (Yitzchak)

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When I started I didn’t really know what to expect. And my plan was to take what I deemed helpful and kosher so to speak especially about inyanim [things/topics] that have a shaychus [connection] to sholom bayis [marital harmony] and bein adom l’chaviero [matters pertaining to between man and man]. I know it sounds baal gaivahdic [haughty], but I’m trying to speak the truth. Thinking about it, like I was saying before, I guess you can say that in my heart I created a mechitzah [division] – let’s stick to psychology and anything else is to be avoided. I think what happened was during the times in conversation he [my therapist] commented on something particular, I would end up responding in a way of trying to see if it fits with yiddishkeit [Jewish philosophy], which then became part of the back and forth between us. Trying to make sense of it in a way that was important to me…

I’ll give you a dugma [example]. So, for example, I remember when we were discussing my being short-tempered and irritable and how it effects those close to me. My therapist asked me about my sleep and wanted to know if my sleeping less than 5 hours a night has a role. I explained that learning Torah was our obligation and I am not just wasting away the hours at night with shtusim [trivial things] and other za’chim [things] and I quoted many mekoros [citations] that support this. He asked me if there were any other opinions on this and the idea that getting sleep could be a mitzvah [good deed] and part of kedusha [holiness], which led to a discussion about the Mesillas Yesharim and the Chofetz Chaim who would explain that lack of sleep can be the yetzer hara [evil inclination] and

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that relaxation is part of avodas Hashem [serving God] if done with the proper kavonos [intentions]. (Yaakov)

1.4 The role of stigma.

This subordinate theme discusses the challenges and obstacles Orthodox-Jewish patients face when seeking and being in treatment. The stigmatization reported by participants emerge in two modes: externally generated stigma, a fear that community and family would view a therapy patient disparagingly; and internally generated stigma, a self-imposed perception of being inadequate or defective for needing to utilize therapy as a resource.

To be honest I find it interesting. On the one hand, within the circles of people I know I have found that there’s a certain chashevus [high regard/esteem] they seem to hold Orthodox mental health therapists. I mean, more and more people seem to be going into the field and every other article you read in the Binah (a widely read Orthodox Jewish weekly magazine) is about therapy this and that.

But I have heard certain rabbonim [Jewish Rabbis/leaders] speak about therapists in less than flattering terms. Within my family, growing up it wasn’t something I ever recall hearing about or being discussed, you know the idea of seeing or going to a therapist. It was something taboo, like what crazy people did or had to do.

That they were needing to go to a therapist and be in therapy. Somehow, I can’t

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explain how or why this is, maybe just by being exposed to this message, I absorbed it and would never have given thought to going myself – like (laughing) ‘me in therapy, no way!’ But I think in the community now, everyone has a child receiving services and it’s accepted for the kids. But for the adults, not so much, I feel. My husband to this day, if I’m to be honest, I think still is uncomfortable I see someone, like it’s a b’dieved [tolerated, but not ideal] you know what I mean?

(Sara) I have very strong feelings about the community’s attitude towards seeking therapy and those in treatment. I want to use the terms ‘extremely stigmatizing’ when it comes to the Yeshivish Black Hat community, and I don’t think I’m being dramatic here. Being in the medical field, I’m in contact, constantly, constantly, with men and women in the community who suffer from depression and anxiety and things like that, and whenever I suggest meds and therapy it’s like I fell of the planet or something. It’s something I end up worrying about for myself and how I will tell my bashert [future spouse] and what the reaction will be – will it be a deal breaker for a good shidduch [marriage prospect]? And taking meds?

Antidepressants not major psychotropics or anything like that – forget it, I worry about talking about this all the time… I can’t discuss this even with my own mother! I tried, don’t get me wrong, I did… For her it’s always ‘daven [pray] more’ and that’s her solution for being an older single and dealing with the frustrations of singlehood – ‘more emunah [belief] and you shouldn’t or wouldn’t

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be sad, deal with and accept the nisoyon [challenge/test].’ How’s that supposed to make me feel? But simply suggesting that maybe therapy would be helpful, or maybe medication to get me through for a time, not a chance! So, what message do you think I walk away with? How many people are left struggling when the message is this? It’s a chaval [pity], really so sad. (Rivka) It’s my reality at this point. And I accept it. I’m divorced, am attracted to men, and go to therapy. Any one of those raises eyebrows in the community – so yes, I keep it under wraps and don’t advertise them. It’s not like I can be at a Shabbos table and just talk about it openly… I grada [happens to be] once dated a girl and quoted something from my therapist – she asks me what kind of therapist I go to and I say my psychotherapist. She looks at me funny and says “what’s that exactly?” So, I’m trying to explain it to her and she’s looking more and more weirded out like I’m crazy or something. It’s a wonderful thing therapy and for me has really been lifesaving, but I look around sometimes at other people and compare myself to them and it ends up with me thinking not great thoughts about myself. (Yitzchak) Well, I mean, b’emes [in truth], it was very difficult for me in the beginning. And to his credit, I think he, my therapist khopped [understood] right away and handled it well, put me at ease. What do I mean? I was very worried about me and my family’s reputation and how it might affect their shidduchim [marriage prospects]. Let’s be honest here, you and I both know as much as we can talk

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about therapy being a good thing, a mai’lah [strength], at the end of the day when it comes to shidduchim why go with such a family when another doesn’t have this – doesn’t have a father who goes to therapy? Maskim [agree]? But like I said, he was and is, of course, very careful and sensitive about confidentiality and that helped. Still, I still every now and then find myself walking out of the session shaking my head and thinking ‘Yankel you’re seeing a therapist?!’ I wonder what the Rosh Yeshiva [dean of the school] might think if he knew?... Now that we’re talking about this, there’s noch a zach b’emes [something else] to this as well, although it’s a shtickel krum [a little convoluted] when I think about it now.

L’chatchilah [originally], I thought that efsher it was a lack of bitachon [faith], you know, going to a therapist – I needed to daven [pray] more, learn more efshar, and the Ribono shel Olam [God] would make sholom [peace]. Ich veist [I don’t know]. Maybe I thought it was an onesh [punishment] for something in my avodas Hashem [service of God], you know? So, I was l’chatchilah [initially] against it. I tried to be mechazeik [strengthen] in my learning. I know that its krum [convoluted] such thinking now, but that’s what was part of it back then. Nu, nu, ah zoy gait dus [that’s how things go sometimes]. (Yaakov)

Superordinate theme #2: Orthodox-Syntonic treatment process.

This superordinate theme answers the research question: “What about the therapy process feels helpful to Orthodox Jewish patients?” and embodies the idea that while not

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all content and discussion may necessarily pertain to religiously connected issues or conflicts, for the Orthodox Jew, a therapy climate and milieu in line with their idiosyncratic religio-cultural upbringing does indeed play a prominent role throughout the treatment process on both a conscious and unconscious level.

The four subordinate themes under this heading are: 1. Religious Paraphernalia/Symbolism 2. Therapist Attire and Self-Presentation 3. Transference 4. Sense of Privacy and Confidentiality The psychoanalytically derived ‘essence’ of this theme is that the influence of the religio-cultural upbringing of Orthodox Jewish patient, is not limited to the specific content that occurs between therapist and patient but also extends to the phenomena which make up the therapeutic process.

2.1 Religious paraphernalia/symbolism.

This subordinate theme discusses the importance that religious articles and overall décor of the therapy room play for the Orthodox Jewish patient throughout the process of treatment.

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I wanted to say that there’s something really comforting for me about her, my therapist, office. ‘Familiar’ and ‘reassuring’ are two words that come to mind (smiling). She has gedolim [famous holy Rabbis] pictures and even pictures of my favorite Rebbetzin [female mentor] on her wall! Every so often, especially when our discussions are touching on hard stuff, I’ll find myself looking at the pictures and for some reason in addition to what my therapist and I talk about I feel a sense of hope. Like it’s a reminder of ‘Whose’ in charge. I think also, that I find myself kissing the mezuzah and actually whispering a tefillah [prayer] for si’yata Di’shmaya [Divine assistance]. Definitely in the early period of when I started therapy, I was nervous, you know? I had no idea what to expect and was really not educated well about psychology. I think that coming into such a familiar environment was just so helpful and really continues to be. I just feel comfortable there, you know what I mean? (Sara) She must share her office with her husband or something like that, because the bookshelves are lined with seforim [Jewish books/literature]. I know it seems like something which is small, you know, what her office looks like, but for me it’s helpful, kind of creates an aura of holiness. I guess others might feel uneasy speaking about certain things because maybe they’d think it would diminish the kedushah [holiness]. But I don’t see it that way really. I see it more symbolically in that despite what might be regarded as negative conversation or inappropriate, for me the seforim [books] and the atmosphere it creates is symbolic that its holy!

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I mean, therapy, at least my therapy involves the search for character development and growth, and yes, of course we have to talk about some of the obstacles and difficulties that prevent it and get in the way, but it’s nothing which isn’t mentioned in the seforim [books] so I don’t see it as taking away or being inappropriate or uh, detracting from their kedushah [holiness]. I do think of my therapy as a stimulus and being holy work. (Rivka) It’s something that is seen throughout this community in all the stores and agencies, including the barber shops, doctor office, the LRRC, everywhere. In the waiting area the magazines, the papers, are all Jewish the Yated, Ami, Mishphacha. There’s even seforim [Jewish books] there. I never thought too much into it until now, but I think it kind of makes you feel normal. It definitely made me feel that way. I don’t know how to explain it exactly, maybe you can.

But for me, on some level maybe uh, maybe, what do you call it, subconscious, it makes me feel like therapy is not so different from other places I need to go like the doctor and dentist. I think that’s helpful for me. (Yitzchak) The Rambam [Maimonides] talks about the importance of si’viva [one’s environment]. And, when I first came, you know, coming into a si’viva [environment] that has devorim sh’bekedusha [holy things] was very telling for me about the therapist and his hashkofos [ideals and values]… I was looking at the seforim [Jewish books]. I didn’t just appreciate the fact that there’s seforim there, but the type of seforim he has. And believe me, I looked for that, it’s

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comforting for me. The way I see it is that means that on some level whatever my therapist is talking to me about is being filtered through a kosher prism – obviously not daas torah [word of God], but still it’s important that his words and thoughts have this foundation. And he has plenty of seforim in his seforim shrank [bookcase] in his office. A lot on Mussar [ethics], and shailos v’teshuvos [Jewish response]. It really made me feel comfortable with him and just the idea of therapy and him as a therapist too. (Yaakov)

2.2 Therapist attire & self-presentation.

This subordinate theme discusses the importance which Orthodox Jewish patients attach to the projected person of the therapist, whether his/her mode of dress, physical appearance, idioms of speech or other identifying features of the therapist that felt familiar. Participants’ accounts indicated that for the Orthodox Jewish patient, therapist externals play a fundamental role in the establishment of belonging within the therapeutic relationship and process.

But anyways, she’s a gem and wise and very calm and soft-spoken, very softspoken, which I really like. And her whole, what would you call it? Her ‘being’, how she dresses, not stuffy or anything like that, put together, you know like ba’taampt [becoming], tzniusdic [modest], but put together and orderly, it makes it so easy to trust, to talk to her because there’s a shaichus [connection] there, a

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Yiddisha shaichus [Jewish connection] not just a professional one, you know what I mean? (Sara) Like I said, I grew up in Flatbush, not originally from this town. Had a pretty ok education, at least in Jewish standards and don’t really speak in a yeshivish way, if you know what I mean. Half the words I don’t even really know what they fully mean, and what I like about her [my therapist] is the nice balance of how she talks, you know, kind of like a balance between a professional and Jew, not too much on the yeshivish terms, but at the same time most definitely not some professor in college (laughing). Yes, makes the therapy comfortable and inviting for me. I understand her, and she understands me, because we talk the same familiar language, if that makes sense. (Rivka) I seriously considered going out of the community for therapy. For many reasons, which I’m sure you khop [grasp], this being one of them. But I think because he’s really good, and we had a relationship before, when I was seeing him when I was married, and I remember thinking how much I’d be giving up if I go somewhere else out of the community. This way, I mean sitting each week with a frum guy, good hashkafos [ideals], uh, you know yarmulke [skull cap], ben Torah [learned Jew], able to juggle both his professional and Yiddishkeit – you know that’s really what I’m needing!... And he doesn’t conform, wears colored shirts, nice shoes and is totally okay with it. He’s confident and I’d say proud of who he is and what he accomplished – that is something I dreamt about for the longest time. I’m really

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happy I decided to stay with him and stick with it. I’m trying to juggle too, would have been a big mistake to leave him, I think it really would’ve been the first step of going off the derech [path] for me, baruch Hashem [thank God] there was hashkochah pra’tis [personal Divine intervention] and Hashem was looking out for me, and allowed me to finally make a good decision (smiling laughing lightly). (Yitzchak) Can’t remember if I thought about how he would look before meeting him, you know, after speaking with him on the phone. But baruch Hashem [thank God], he looks like a yeshivisha fellow, ich veist nisht [not really sure], like a middle aged yungerman [learning fellow], you know? Probably early 50s b’erech [approx.], dresses like ah yeshiva mahn, like unz’erur [one of us], with a short-trimmed beard and his tzitzis [fringes] out. I grada [happens to be] try not to judge people on what they are wearing, anybody can wear what they want, ohbur [but] for me personally, I feel comfortable when it’s yeshivish. It’s the language, someone who fahrshteys [understands]. I don’t know, makes me feel at home. (Yaakov)

2.3 Transference.

This subordinate theme discusses the role in which transference, as distortion and as in part reality-based, plays in the therapy process of Orthodox Jewish patients.

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She’s an older woman must be in her early to mid-sixties. It’s like I’m talking with my Bubby [grandmother] at times, I have a real affection that I developed for her! My Bubby passed away about ten years ago, I was really close with her, you know had these really long deep discussions. I think that’s why I relate so well to her my therapist. It’s funny although she insists I call her by her first name, I just can’t bring myself to do it. So, I call her Mrs. X… I’ll tell you something interesting. There was this time, around Chanukah I think, when I was baking in the kitchen and for some reason, I found myself thinking about how my Bubby and I would talk and eat cookies together. It was a spontaneous thing, I just started baking cookies and brought them to my therapist at our next session. I know it sounds so weird, but it was such a great feeling, talking with my therapist over cookies, the same way I used to with my Bubby! Yes, it’s definitely a helpful part of my therapy – I mean, some of her mannerisms. Especially with topics about sholom bayis [marital harmony], it makes things so much easier to accept and do – I imagine she has a lot of wisdom from her own life, you know her marriage and balancing being a mother and wife and think that’s why it’s so easy to converse with her. This is embarrassing but I’ll tell you anyways, sometimes, when I’m talking with friends and stuff, and I repeat something my therapist told me, I’ll say it over from my Bubby, only because I couldn’t tell them I’m in therapy. Yah, it’s really interesting. (Sara)

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She’s probably early fifties, but she look’s young, like one of those people who just is younger than their age types. I’ll tell you, kind of like she reminds me of a seminary teacher, no one specifically that comes to my mind, but you know, those young dynamic, smart, future Rebbitzens [female rabbinic figure]. Very put together, not fancy, but always put together, like she has all of her life in order, always calm, just like seminary teachers. I’ll tell you, I was skeptical at first, not sure exactly why or what it was, but that was my experience as a teen when it came to sem and the teachers… She probably was one of those girls that sailed through high school and life – popular, lots of friend because she has a great personality, I’ve always envied those girls, you know, just wishing I could feel so comfortable with myself – and now, I get to see and have a relationship with one every week! For a price that is (laughing)… But seriously, yes, there are times when I find myself using words or phrases she uses, or even hand movements – she has this way of moving her hand when driving home a point. I guess there’s a part of me – the teenage part of me I guess you can say, that just really likes and looks forward to being with her. Oh gosh, I hope this isn’t weird (smiling). But its honest, the truth. (Rivka) Uh, most definitely not someone I know or knew. But I’ll tell you this much, b’emes [in truth] he’s someone who I dream I could be like. He’s accomplished, he’s smart, he knows a lot about psychology but is also very knowledgably about Torah, he’s a real example for me about what a ben Torah [learned Jew] should

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be… I kind of wish that were me, my life. That’s why I like going to see him, at least I have a part of it weekly and who knows, maybe it’ll rub off (smiling)!

(Yitzchak) I think he has yi’shuv ha’daas [clear thinking] and menuchas ha’nefesh [sense of serenity], you understand what I mean?... When you meet with him, there’s epes [something], I don’t know, a calmness, you know? Like things are b’seder [in order/altogether] by him… Something about him my therapist, maybe it’s his calm voice and always appearing calm, never rushed or stressed, it’s something like that… I like it. It’s very good. That mailah [strength] of never feeling rushed, always seeming to have a sense of menuchas ha’nefesh [peace of mind]. Speaking slow and thought out, like everything in his life is b’seder, just in order, you know? So, I guess you can say that I’m me’kaneh [envious of] my therapist (smiling), this pr’at [aspect/detail] and mailah [strength] of his personality is something to work towards for me. But it’s nice to see it each week… It’s good to at least see it in action, you know, when I’m with him. (Yaakov)

2.4 Sense of privacy and confidentiality.

This subordinate theme discusses how the Orthodox Jewish patient views an atmosphere of privacy and confidentiality as integral to the overall treatment process and therapy experience.

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There are two entrances for her office one for when you come and the other when you leave. I really, really appreciate that. It’s hard enough to be in therapy and the thought of meeting somebody or even being seen for me is mortifying. That’s just the reality of things. The fact that she goes out of her way to protect her clients and takes these measures makes me so comfortable in treatment. I think I’d want the ground to swallow me if I met someone I know, it would be such a bushah [embarrassment] for me! I thought about this a lot, good therapy is not only about actual talking, but also about the experience and for me having a security of confidentiality is so important. I feel protected, and taken seriously, like she gets it, the constant worrying about being a therapy client. (Sara) The idea of privacy is major for me and it’s a big issue for me in this community.

There’s something about being heimish [Jewish over-camaraderie] that really bothers me when it comes to the frum professional world. It’s like almost a given, at least from what I’ve seen so many times, even in my own work at the office.

It’s like a given that information tends to be shared, because of the haimishness [over-familiarity] that exists in our small knit community. I really hate it… And the fact that my therapist is so professional about it, makes me feel secure… How do I know? I guess it’s just how she speaks, acts, and the protocols she has in place. Of course, one could never know – I guess it’s a trust thing that comes from just a feeling I get from the vibes she gives off… I once met her in Glatt Gourmet, ugh, it being such a small town and all, and we made eye contact and that was it. I

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appreciated that, although I don’t think I would have minded so much had she come over, or simply said hi. I think that other professionals would have come over, which she explained to me in the next session is really a breach of confidentiality – so it’s things like that. I very much respect that about her and it makes the therapy treatment for me that much more reassuring. (Rivka) I think that trust is a big piece for me and that is a big piece in the beginning.

Probably started from my divorce and it’s an ongoing struggle. Listen, the facts are in this community if you sneeze the whole town knows about it and it can affect your shidduch [marriage prospect]. So, with the things I am dealing with, trusting my therapist is very, very, important for me… I’ll tell you the truth, I really don’t care whether or not people know I am in therapy, I think the fact I’m divorced anyway people expect it. I’m sure people near the office see me going in week after week, but I really don’t care about that. But what I discuss with my therapist, you know, the actual discussion, that needs to be protected for me and for my family. And I trust him explicitly that’s why I chose a private therapist even though its more expensive than going to an agency, because I just don’t trust the information not getting around – and the more people that know – chavra d’chavra es lei [people talk to people]. He’s very professional, gives off a very safe vibe, I can tell from how he conducts himself, he’s very b’seder [orderly], serious, and very professional – and I can tell he’s a private person, maybe too private (smiling), but I get the sense and think that if that’s how he conducts

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himself he must also be that way when it comes to his clients too. I think that at the beginning of our therapy, maybe the first or second session, he actually spent some time explaining to me how important privacy is and I remember feeling thankful that this was going to work because I really was so scared about this.

(Yitzchak) Well, you know, you know how it is. It’s, we are a small community, especially within the yeshiva velt [yeshiva world], which I am a part of. My biggest concern was being found by someone that I am going to therapy, and what they would think. Like I said this before. It’s true, I would also think about what would happen if I would meet him at a chasuna [wedding] or vort [engagement party], and what would happen if we both knew the same people. I worried a lot about the type of discussions we would have and how and if it falls under the issur lashon hara [prohibition against bad speech]. But one of benefits of being with a frum therapist is that you can trust that they know about these halachos [rules] and understand the issues frum clients must have about attending therapy. So, yes, there were times when I asked directly, or he asked me whether I was holding back because of the issur [prohibition] or because I was worried about what he might do with the information we had been discussing. And, I found that to be a very wise way of dealing with this for me. It put me at ease and sent a message that these were matters that he took extremely seriously. Like I said before we actually went through some of the halachos [laws] together also. I once

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mentioned this to him, I think I called him a mentsch, and he told me that in addition to the halachos involved, he was under some sort of law, legally, that didn’t allow him to discuss our sessions with anyone or anybody else’s with me. I liked that. Makes my therapy so much calmer for me. (Yaakov)

Superordinate theme #3: The therapeutic relationship.

This superordinate theme encompasses participants’ varied descriptions and felt experiences regarding the quality of the connection they felt with their therapist. This includes of aspects of the personhood of the therapist, as well as additional components that contributed to the establishment and continuity of the therapeutic relationship.

The three subordinate themes under this heading are: 1. Empathy 2. Sense of Equality 3. Going the Extra Distance The themes psychoanalytically derived ‘essence’ captures the idea that despite a wide range of factors listed as being part of a successful treatment, all participants saw their therapist and the alliance with their therapist as anchoring that experience.

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3.1 Empathy.

This subordinate theme speaks to the importance and essential role empathy plays, both, as a mode of clinical observation and as a mode of responsiveness, for fostering an effective treatment in the eyes of the Orthodox Jewish patient.

I don’t think she’s ever told me that she has kids, not that I can recall anyways. I assume she does, but I don’t know for sure. But she gets it so well! You know, or maybe you can’t because you’re a man (smiling, light laughter). The feelings of being a mother, bringing up kids. The negative ones that is. The constant feelings of guilt, that we aren’t doing enough, that we are responsible, it’s like beating myself up again and again all the time. And her reactions are just loaded with the feeling that she really gets what I’m saying… Uh, how can I explain this better?

I’m not talking about knowledge, the type you get from reading books, parenting books and stuff. I’m talking about my feeling that she’s really a part of my experience – cliché but like walking in my shoes. And it makes me feel so calm afterwards. I remember this one session, I had so much on my mind, it was a crazy day, crazy week, I was yelling at the kids, much more than usual for me, and I had just so much to talk about. And I show up for session, and for 60 minutes, literally, b’li guzma [without exaggeration] just let it all out. And she just sat there, listening, I don’t think she really said much, but she was so present, so there in the moment you know, and after, when I walked to my car, I felt so understood. So, I come home and my husband, in a rare moment, because he

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usually never asks, but I guess I was in such a state before I left he asked, so he wants to know what the therapist did and said to me that I was so calm – and I explained to him she listened. He didn’t believe me, like he was in shock and disbelief! How can you explain that to someone? I think he just response something like, “what an easy job.” Honestly, I can’t blame him, unless you experience this, it’s difficult to explain and understand. (Sara) I think she’s super compassionate. She cares. Simple as that. This is especially important for me… I once went to a shiur [lecture] on marriage and how to have good sholom bayis [marital harmony] … and the speaker was talking about having an emotional ‘bank account’, so that there’s enough good interactions and memories to draw on so that in times of conflict the hurt spouse can draw on that to get them through the conflict. You know, I’m sure you’ve heard this before, to kind of, to remind them that their spouse really is a good person and that would serve to help them get through the rough patches. But I think it’s the same thing in therapy you know. Listen, there were plenty of times when I didn’t appreciate some of the things she said or recommended. And there were several times I was upset at her behaviors – like the time she scheduled me and forgot about the session because it was her lunch break – but you know what, I think her overall way of being with me, outweighs this for me. It’s like I feel anger or something, and then there’s another part of me that is able to tell myself that overall, she’s really caring and is there for me. The emotional bank account. (Rivka)

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I came into therapy being so disconnected. Not only with people and former friends, but with myself. Like who am I? The person I thought I was, wasn’t me.

Thoughts and some feelings that weren’t a familiar part of me. I had and still have a huge fear of being cut off from my family and from my community. But even more so, I really believed I was beyond help. I mean, how could a therapist exactly help me? There’s no solution for my struggles. It’s not like he can offer me some advice that will help with things. You know what he said? He told me, “I know I can’t solve this for you. But I can and will make every effort to share in your struggle and pain.” And I remember I began to cry – one of the only times in my life. I’m not talking teary-eyes, full blown crying. And I never felt so close to someone than that time. It’s one of the main things that has been helpful for me because from that moment on, I felt able to share. And I know he doesn’t and can’t agree with my thoughts or ideas, but he allows me to at least talk about them in the open without having to pry or pull teeth. Just by being accepting.

(Yitzchak) I’ll tell you what’s really good about him [my therapist] he’s an emesdica mentsch [honest/genuine human being]. I’ll tell you a story which to this day I am still working towards, but which really made a roishum [impression] on me… We were talking about looking back at life and the idea of regrets – in life in general, as a parent, and as a yid [Jew] and some of the other responsibilities I play. And I was telling him how difficult it was for me to have to accept some of my

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children’s choices and decisions and how many hours I spend davening for siyata di’shmaya [divine assistance] in chinuch habonim [raising children], right? So, I’m talking, and as I’m talking, I’m looking at him and he’s mamish [really] almost crying. There were tears in his eyes. And I stopped. So, he realizes I stopped, and he asks me about it. I tell him I’m reminded of the story of Rav Moshe who began to cry when a mother came to him for a sh’aliah [question] for a serious p’sak [decision] about a medical procedure and she came with her doctor and Rav Moshe began to cry after hearing the story. It was powerful and really affected me. I told him that I wish I could be like that and have been working to get to that madreigah [level]. But it made me think of him in a whole different light after that. This is a man who is emesdica [genuine], it’s not just about money. He really cares and feels for his patients. You can’t fake that right?

You just can’t. Isn’t that moiridick [unbelievable]? True maisah [story]! (Yaakov)

3.2 Sense of equality.

This theme speaks to the importance which the Orthodox Jewish psychotherapy patient attaches to being accepted for who they are and of not being criticized for failures in life or as people. For the Orthodox Jewish patient in particular, it is helpful for the therapist to provide a therapy which does not deny the exigencies of their realities; but in which those realities do not proscribe their being perceived as people and which offers an

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overall quality of respect; not one in which there is a feeling of being demeaned, rejected, and/or threatened.

So, in the beginning, I felt very self-conscious. Here I was talking about feeling like a failure as a mother and wife, as a person. And she seems to have it all together. Like a successful career, sane home life and family. I think I felt like “yep, here I am, not as good as you. Yes, you’re better than me. You’ve got it all figured out, I’m lost.” I’ll admit it, I was a little resentful… Yah, resentful of her.

But very quickly, she normalized my experience and life. And what a relief, huge difference it made for me. I mean, who wants to feel demeaned or threatened by their therapist! But, I really think it was all in my own mind. Over time, this changed, I changed I guess. One time, I brought her hamantashen right before Purim, and she liked them so much she asked me for my recipe! It was like she was telling me that I have what to offer in this relationship as well. And that it wasn’t she who was judging me, it was me who was judging me. (Sara) When I go to simchas [parties], like chasunahs [weddings] or vorts [engagement parties], I get the nebech [pity] look and greeting. You know what I mean? It happens all the time. Like my favorite, the “im yirtza Hashem [God-willing] by you” comments. Not just the words but how they say it, with the pitying eyes and expression. I hate it, you know? I came to the simcha [party] to enjoy myself to be happy for the baal simcha [the host], so why do I have to be reminded of my sad situation? So, in therapy, well, at least in my therapy, what’s really great is I’m

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not simply viewed as an ‘older single’. Like there’s nothing more to me than that.

I like that she gives me the genuine feeling of being a lot more than my struggles.

I think this is a very important part of any good therapy – people need to be made to feel like their people, you know, not just nebechs [failures]. I mean think about it, if we’re at the point that we’re coming to therapy, we really can’t be thinking or feeling too great of ourselves, so why harp on it? Can you teach that or is it something that therapists need to develop, a mindset? But whatever, when I think of my therapy that’s one of the things that stands out most for me, being treated fairly and whole. (Rivka) I’ll tell you. What I really find to be helpful as well, is that I don’t feel judged and that was and always will be a huge issue for me… Like every now and then I wonder what he must think of me – being divorced and the other issue as well, but I’ve never, not once, got the feeling or impression that he looks at me differently or looks down on me… Why is it helpful? Uh, it preserves my sense of dignity I guess, doesn’t make me feel embarrassed, like I don’t have enough of that anyways (smiling). It’s nice to feel like a human, you get what I’m saying? I think if he can accept me or treat me as equal, then I can be accepting of me and all the parts of me as well. Something like that. (Yitzchak) My therapy is a shaklah v’taryah [give and take]. I like it that he, my therapist, doesn’t make me feel like I’m meshugah [crazy]. He asks me questions about certain things and listens. Several times he’s asked me the mekor [source] for

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certain halachic rulings or which sefer [Jewish book] he can find them in.

Sometimes he will write it down, some of the ideas I tell him. I feel like he respects me and doesn’t look down on me, like he’s the doctor and I’m like an am haaretz [ignoramus]. (Yaakov)

3.3 Going the extra distance.

This subordinate theme highlights how the willingness and flexibility to go beyond the boundaries of formal roles is important to the Orthodox Jewish patient in that such activities are perceived as differentiating between a particular therapist being paid for services versus a therapist who has a sincere desire to help rather than just fulfilling a prescribed responsibility.

The truth is from the get-go I questioned therapists. I mean, let’s face it, you’re paying them for services. So how can you really trust that they really care about you, even when they say they do? I think it’s a fair question, but I never asked that to her, you know? I’m the type of person who feels uncomfortable in just ‘letting my hair down’ to just anybody. There are some women, and I have several friends like this, who will tell all in a conversation with just about anybody. They’ll talk about their marriage, job, and struggles with them, in a conversation with their neighbors in the complex. They don’t even know these people that well, and I can’t get over how they can just talk so freely about this. I

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need to have the feeling that the other person is not only trusting, but wants to listen, and really cares about me because it’s just their character, who they are…Yah, she gained my trust. In the first or second session, I was shocked when, we were discussing my family and children, she asked if I could bring in photos of my kids and what their birthdays were! And she remembered them! She calls me on my kids’ birthdays and wishes me mazal tov and encouragement! My close friends don’t even do this. That’s very telling to me. Yes, she’s a professional and yes, I have to pay for her services which is to help me. But at the same time, she’s more than just a woman who takes my money. She cares about me in a real way, and that shows me it’s not just business as usual for her. (Sara) It’s been almost a year actually, I was going out seriously with this boy. I really thought this was it, you know? Like finally, it was happening to me, I could join the world of marrieds! Yay! And all that. And of course, my therapist was involved from the beginning of our dating process. I mean, we discussed every date, my concerns and fears and helped me with questions I had about the boy. It was actually really helpful, and I was ready you know, not so much him though, but I guess nothing out of the ordinary I thought. Anyways, it got to the point, that I remember how she offered to see us both before and if we would both want to get engaged. And then on that Sunday, I’ll never forget it, we went out and he broke up with me on the date, if you could even call it a date. Whatever, the details are not important, but I was shocked and devastated. I mean, I really didn’t

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see it coming and the shadchan [matchmaker] didn’t give me warning either, although to be fair, she wasn’t so involved at that point, the truth is. So, I’m sitting in my car, balling my eyes out, right? I didn’t even know what to do or whom to call and I’m feeling so desperate. Should I call my mother? My friends?

Ugh, it was not good. I know my therapist doesn’t see clients on Sundays, but I really needed her, just to hear her voice at least. The second she heard my voice on the phone and what happened, without a second, she told me to come to see her and that she would be at her office for me in 30 minutes! I was in such a state then, I couldn’t even recall what we spoke about or what I told her, but I think the fact alone that she went out of her zone so to speak to see me at a time when she doesn’t usually see her clients, that itself was healing for me. I felt so alone and misunderstood and hurt, and that she was able to see me at the spur of the moment, meant so much. I felt like I had someone there for me, I wasn’t alone, and uncared for… I mean I knew she cared before then, so this was something different beyond that, like it showed an extra level of caring… By the way, she refused to take money for that session. When I insisted, she insisted back, and told me I could repay her by one day returning the favor to someone else in need!

That’s not just a professional, that’s a real genuine human being! (Rivka) You’re a therapist, so you would know this, I hope. I believe that many of us who are going to therapy, especially within our community, want a therapist who’s going to go the extra mile. As it is, going to therapy is hard. I speak for myself

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here, but I’m going to imagine many would agree with me. We Jews are know it all’s, especially us men. So, to have to come to a point, where we are going to see somebody for help and advice, and pay for it no less, well, it must be really bad, and it’s extremely shameful. No one wants to admit they can’t solve their own problems, and we will do and look for whatever we can to find fault with a therapist, so we can tell ourselves why we shouldn’t go and waste money… Trust me, I’m talking about myself as well. So, I made my therapist work hard to get my trust. I wanted to know that he saw me more than just a parnasa [means of financial support] … So, I would test him, in all sort of ways, you know. I’d want to see if he’d remember things I told him, kleinakeit [small/insignificant] things you know? Like names of friends or people I mentioned in discussion with him weeks before. And then one time I was making a siyum [celebration] on a masechta [volume of the Talmud] and I invited him to the siyum. Now, I’m aware of his rules, he’s told them to me in the beginning of therapy, and I thought this would be a pareve [grey] area, and that he would say no off the bat…

Surprisingly, he asked me about the location, day/time, and said he would be honored to come for a bit and wish me mazal tov in person. And he did! Usually, and knowing him, this would be something he’d want to talk about in session, you know to see other parts of it. But, he came, walked over to me with a big smile, and told me he was very proud of me and honored that I invited him. That was

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when he got all of me invested in therapy. Yes, he passed the test! I am not just a parnassa for him. He really cares. (Yitzchak) Well, yes, he, at times, he goes over time for me when I need it… It’s happened on many times when I was in the middle of something important and didn’t just end at the 45-minute point. This is a big zach [thing] I think. He’s a very punctual fellow, like I said before, but certain times, he doesn’t just end when we are supposed to. Also, sometimes he calls me in the middle of the week just to see how I’m doing… if, especially if I’ve had a difficult session… Because it’s things like this, that send a message that more than just a therapist, he’s an emesdica [genuine] person first, who cares about the people he sees. This is something very important to me. Says a lot about him, not just that he’s a professional therapist, or something like that, but it tells me about the type of mentsch he is. That he sees this type of work as more than just work. And it gives over a very important message to clients, at least to me that, that we matter and that the therapist is more than just a thing that exists when it’s a session. (Yaakov)

Superordinate theme #4: The therapeutic factors.

One of the research questions in this dissertation asks: “What are the specific beneficial elements of the therapeutic encounter as experienced by Orthodox Jewish patients?” which captures the idea that effective therapy in general and the therapeutic

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experience in particular, is an enormously complex process that evolves through an intricate interplay of therapeutic factors. This superordinate theme entitled “The Therapeutic Factors” underscores how the total phenomenon can best be understood through its basic component processes and elemental factors, which although discussed singly, are interdependent and represent different parts of an effective therapy experience.

The five subordinate themes under this heading are: 1. Self-Understanding 2. Psycho-Spiritual Integration 3. Psychoeducation 4. Highlighting Strengths 5. Climate of Hope The themes psychoanalytically derived ‘essence’ is that patients of psychotherapy can supply data about the therapeutic factors they consider most helpful and should be considered a rich and relatively untapped source of information. Focusing on beneficial therapeutic factors from the perspective of the patient is a very useful way for therapists to shape the therapeutic experience.

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4.1 Self-understanding.

This subordinate theme discusses the benefits Orthodox Jewish patients attribute to self-knowledge and understanding. Whether it was the discovery and acceptance of previously unknown parts of themselves, insight into the relationship between past and present, or learning why they think and feel the way they do, participants report that selfunderstanding allows them to experience a wholeness and deep sense of liberation.

I know I said this, but when I started therapy, I was in a panic. Both inside and outside, I was like panicking. It was becoming unbearable and affecting my functioning as a person and as a mother. It was like things were spiraling out of control at a quick pace. Mamesh [really] crazy. I had a vague understanding of what might be at play, but vagueness apparently isn’t enough. Looking back, I guess what I was needing was a way to make sense of it all, like an explanation of sorts. And I think that’s what was so helpful. Knowing that I have always needed people’s admiration, always saying yes, yes, yes, turned me into a shmatte [doormat], leaving me with feelings of resentment, anger and hurt. This knowledge allowed me to make more sense of a lot of things not just in therapy, but to situations in the outside world as well. Knowing how and sometimes why I operate a certain way has been very beneficial for me personally, baruch Hashem [thank God]… I remember when this finally came out in therapy, my therapist recommended a family session with my husband and I found myself just going with it, her suggestion, you know, saying yes and agreeing, thinking the usual

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thoughts of “what do I know anyway?” But it felt off, it didn’t feel right, and I got the courage to tell her “no!” that I didn’t want him to come at that particular point. And we spent some time processing that interaction and moment. It was really an amazing experience and break-thru for me! I still feel proud just talking about it now (smiling)! (Sara) So, a lot of my work has focused on my being an older single. And it’s confusing right? I think I am a good person, so why can’t I find the right guy? Am I doing something wrong? Is there something or some message I give my dates? People in general? And on it goes. So, we focus a lot on that. And she is great with this. We looked at other relationships I have and had, trying to figure out patterns. We spend time on the past you know, the earlier periods of my life. I remember being a bit apprehensive about that. I really didn’t want a therapy which gives me an excuse for my stuff – I didn’t want to be one of those people who blame it all on parenting, childhood and all of that. But it was nothing like that. Rather, and this was really to her, my therapist’s credit, we dipped in and out of my past and it was really eye-opening! I have learnt that I react to some people or situations unrealistically with feelings that belong to earlier periods of my life and this has been extremely helpful for me. This type of understanding on the one hand gives me greater insight into how and why I sometimes may act like I do. It’s been helpful to know how I feel and behave today is related to my childhood and development meaning there are reasons in my early life why I am the way I am,

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because it still doesn’t absolve me from responsibility and allows me to be more aware. I love learning about myself and this has most definitely been an instructive and main part of what I believe makes my therapy successful. (Rivka) Whatever positive thoughts or feelings I had for myself, went out the window, and can you blame me? I was struggling with feelings that probably will have tremendous ramifications are probably against my religion and certainly far removed from what my community believes and tolerates, I failed in my marriage – what did I have? I hated myself, I couldn’t stand most parts of who I was…

Through therapy session after session, my therapist again and again, allowed me to talk freely without judgement, I was able to somehow rediscover the positive parts of who I am and the person I am. It’s an amazing thing and feeling. Unless you’ve experienced it, I can’t describe it with words, you know? Yes, I am still confused about my feelings for men, but I’ve come to accept this – it’s maybe just who I am and doesn’t have to negate all the other parts that make me Yitzchak.

And there are many good parts of me – I am compassionate, there’s no way for you to know this obviously, but I care very deeply about people, even for my exwife. This was and still is one of the best parts of my therapy and how it has been helpful for me. I can’t explain how this happened or whether my therapist did something specific, I don’t think so. And it’s not something I realized right away, you know, like there was this moment. But it was over time, like one day, I just looked at myself and how far I have come. My therapist calls it “the process.”

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And it’s like I feel whole again, I can’t explain this any other way, it’s just a feeling that’s really hard to put into words. You know, like a puzzle, before it’s put together, its 1000 pieces all over the place, and that was me when I started therapy. But worse, because I wanted and maybe I did, I threw away some of those pieces, I didn’t want them. I don’t think the puzzle is complete but it’s getting there and at least I can deal with all the pieces! I am okay with all the pieces. It’s like I found a new me, but that ‘me’ was there all along. (Yitzchak) I am an intellectual, I use my seichil [rational mind/logic] just about all the time, and don’t act on emotion. I know this, and I’ve been told this by many people, including my therapist. It’s part of how I grew up, and I think learning for so long, which is always about analyzing, examining, also causes this. My tateh [father] he was the same way. It’s one of the things I enjoy about therapy, I get to examine myself, learn about delve into myself and perhaps why I am the way I am. And my therapist will actually tell me if I am doing this too much… So, some of my work is to ‘soften’ a little, you know, be more, ich veist, more expressive of my feelings and I am working on that. But I don’t think it’s just simply an exercise for me, like I’m a sugya [puzzle] to figure out and make sense of that is helpful, no, I think it’s more than that. Having a better understanding on myself, learning about these things, is relieving because it removes uncertainty… So, b’kitzur, uh, there’s something helpful about breitkeit [clarity] or at least making sense of confusion, of not really understanding certain things – especially if it’s about

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yourself and how you’ve been. That’s the really helpful part for me, it’s not that I ever thought I was meshuga [crazy] or something, but I definitely struggled with trying to figure out why I was constantly finding myself in similar types of situations with some people. And it created a real pachad [fear] the not knowing I mean. So yes, if I’d have to say what was helpful, in my opinion this part of therapy was. (Yaakov)

4.2 Psycho-spiritual integration.

This subordinate theme highlights the benefit Orthodox patients place on a therapy which integrates religio-cultural and clinical expertise. For the Orthodox Jewish patient whose presenting problem might be tied into some form of psycho-spiritual distress or interconnected with a salient religious conflict, having a therapy which successfully synthesizes both the psychological and spiritual allows the patient to be fully seen and understood and is vital to their growth in treatment. Whether it was the perceived connections between the secular concepts in therapy and beliefs found within a religious framework, or whether passages from the Bible resonated with ideas used in therapy, this integration allowed for a reconceptualization of therapy whereby psychological and religious insights were increasingly regarded as complementary.

Being able to talk about Hashem [God] is something which has been helpful for me in my therapy. What is my role as a mother and what does Hashem expect of

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me and working through and talking about my relationship with Him and the feelings which come along with this makes me feel at home with my therapist.

It’s comfortable, you know? I want and need my conversations with my therapist to be no different than with my friends and I expected to be able to talk about this comfortably. Of course, it’s not the same as with my friends but what I mean is the topic should and needs to be open to talk about for me. I’d imagine there are people who might disagree, but I think that they would need to talk about certain aspects, you know, like fears, or even anger, things which are generally not spoken about in such a way with others, but at least the therapist should offer and be able to have such a discussion. It’s such an important and primary part of any frum yid’s [religious Jew] life I cannot imagine how it can be avoided or if that would be helpful. So yes, good therapy with frum Yidden needs to incorporate this. From the little that I know, I don’t think psychology is very big on this, at least that’s what I remember hearing from one of my seminary teachers. That has been one of the benefits of working with a frum [religious] therapist, she’s able to listen and understand and our discussions don’t come off as a bunch of frummie women chatting about Hashem. I have felt comfortable over time, to really look at my beliefs – my emunah [belief in God] and bitachon [faith in God], and how I actually view my relationship with Hashem and Torah and mitzvos. And she’s open enough to allow me to talk about some of my challenges with some of these, without making me feel ashamed or bad. I’ve never had that before. (Sara)

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I don’t think I realized this at the outset of my therapy, and it was definitely not something I was looking for or maybe even thought would be important for my therapy at the time, but I’ve given it a lot of thought since you’ve contacted me and thinking about it I would say that having therapy which can focus on or acknowledge the importance of our connection to hashkafa [Jewish ideology] or I guess ‘spirituality’ might be the right lashon [term], is really important and for me is very helpful. I am not sure if a non-Jewish or even a non-frum [not religious] therapist can provide this because I know for myself I could not fully connect or accept the ideas such a person would put forth, in the same way my therapist, a frum woman does. I guess I’d always be doubtful if it represents kefira [blasphemy] or if it is line with frum, Torah hashkafa [ideology]. So, for example, for a period of time, I was really down probably diagnosable depression. Things weren’t going well, I just broke up with a guy who I was dating for a while and seemed shayich [viable] was in a fight with my mother, and just couldn’t bring myself to daven [pray]. So, in addition to everything else, I was struggling with my relationship with Hashem [God], doubting my frumkeit [level of religiosity], and having tons of guilt over it. My therapist and therapy sessions during that period, focused on many aspects of tefillah [prayer], and she was able to draw upon and educate me using different sources about tefillah and ways in which the way I was feeling might not be helpful. For my therapy it was and continues to be a very important and I’ve come to find necessary part of good treatment for me. I

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think it was something which I was so badly needing to have a discussion about, and it really deepened my therapy by us being able to talk about these things. I’d imagine any frum yid, man and woman would be needing this to be a part of their treatment. (Rivka) I think so much of my anxiety is tied up with my parents and how to balance kibbud av [honoring one’s parents] and what the Ribono shel Olam [God] wants of me, with what’s acceptable for my own well-being. It’s hard not to feel guilty when you’re not a good son, but even more, when you think Hashem is upset or not happy with you as well… I really appreciate and admire the fact that at certain points in my therapy, my therapist suggested that my Rov/Rebbi be brought into the discussion because he felt it would be helpful for us, me and him, to hear the daas Torah [religious knowledge] perspective in addition to what he was able to provide. And I’ll be the first to admit it, I feel sometimes so empty, like my neshamah [soul] ran out of gas or something like that, and it gets me depressed and anxious. At the end of the day, I’m a yeshiva guy you know, and what I like about my therapy is being able to talk about this, but not getting the “mashgiach [spiritual advisor] response” which is typical, and most guys will tell you is just being told to learn and daven more. My therapist has framed my relationship with Hashem in a way that feels like my relationship with my father. Like never feeling good enough, always hoping for more closeness. And, like I said, I like that I can express my doubts and not have to worry about being shut down or

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being made to feel like I’m a kofer [blasphemer]. I feel like I’ve grown more genuine and real in my appreciation with Yiddishkeit and hashkofa through this than learning in yeshiva [religious school]. (Yitzchak) I realized, quickly, so much of psychology has its shoresh [roots] in the Torah, and I think for me a helpful and important part of it is that the therapist be familiar with both. It makes the treatment much more meaningful when there is a Torah source to what he is saying or explaining. I mean, at this point, I really can’t understand how you cannot have it, I mean I need to be able to talk about haskofah [outlook] and tafkid [purpose in life] in addition to figuring out my relationship with Hakodosh baruch Hu [God] and how emunah and bitachon play a role in my life. I need to be able to hear a different view on my understanding of what’s my own versus what is the correct understanding of a Torah concept… a balanced package is what I think is one of the most important parts of therapy for people in our community for sure the yeshivish crowd. Look, I think it’s impossible for it to be separate, you can’t not include it in therapy and there’s no way I would ever have considered looking for therapy or a therapist who couldn’t talk knowledgably in areas of halachah [Jewish law] and haskofah [philosophy], especially since so many of the issues are tied to this. Even though I don’t think I realized it at the time, you know at the start of my therapy. Even sholom bayis and tahras hamispachah [family purity], these are such main parts of our lives, and not understanding this and being able to talk about it in therapy is a shud [shame]!

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In my therapy I talked about so many of these areas, olam haba, bechira, sholom bayis, yetzer hara, and while I don’t agree, I’m not always maskim [in agreement] with everything he puts forth, at least I feel comfortable that we can at any time include this in my therapy. I would not be able to imagine it being any other way, le’chorah [ostensibly]. (Yaakov)

4.3 Psychoeducation.

This subordinate theme speaks to the importance psychoeducation plays in the treatment of the Orthodox Jewish patient. Education is paramount for the Orthodox Jewish patient because it demonstrates respect by engaging them as a full-partner in their treatment, it decreases ambiguity, and, on a meta-level, gives the patient knowledge and realistic expectations regarding the prognosis for cure affording them the ability of creating realistic goals.

Let me tell you, for me, the worst part is the not knowing for me. When I came into therapy, I thought I was crazy. You know, it’s not easy coming to the decision to go. For me, I created a whole anxiety imaginative explanation for needing to go, especially since my son’s therapist recommended it as well. Like, what’s it supposed to mean if a professional is telling you to go for therapy? Like, maybe I had some personality issues or mental illness and would need medication which is my biggest fear. I cannot describe the sense of relief I experienced when

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over several sessions, my therapist explained what a personality disorder means, the different types of depressions and anxiety, and how my situation, you know – having a growing family, maintaining the house, and holding down a job, would create stress, worry and anxiety for any human being. It was like a weight was taken off my shoulders… Also, every so often she’ll help me understand what would be considered ‘normal’ so to speak, for my children and their behaviors by educating me on what’s to be expected depending on the age of the child… Why is this helpful? Well, for me specifically, I have a hard time not knowing my mind runs wild trying to come up with some explanation or reason for something. I think being told by a professional, you know an expert, and someone I trust about these things and being given information about these things – even if it’s not such great information, like who wants to be told that they have anxiety or things like that, but still it’s comforting. At least I know what I am working or dealing with and I can deal with that. (Sara) You know what I hate, when your sitting there and the therapist is writing things and you’re left wondering “did I just say something that makes me crazy or something? What did I say that needed to be written down and what are they making of that?” So, I told her that it makes me feel weird when she does this.

We spoke about it, and she clarified exactly what she was doing and what she wrote and why. Ever since then, she always explains to me things and why she might be doing things or saying things in a certain way, for example. Like, she

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usually won’t just answer a question I ask of her, and it was really bugging me, I guess she picked this up and we discussed this – also, why this was so annoying for me. I felt much better after these type of discussions. Like I’m a smart respectable person, and not simply a patient who is sick and being analyzed by some person who gives off this impression of having some great knowledge about me that no one else, even myself, know about me! I think anyone would appreciate feeling like their therapist respects them as an intelligent capable human being – it just makes sense to me. (Rivka) I remember when I came back to him, I told him that I really wanted to learn about relationships. My therapist was really good with that and like explained to me different things about it. Like different styles of communication between men and women, he also introduced me to a guy named Gottman and some of his marriage views. You know, for me it’s important that we not only just talk and talk, but I need some le’maisah [practicality] as well. Goals to accomplish and real ways of how to get there. I need to know clearly how to do things differently and an explanation of the psychological reason for things, I really like that, it helps me to understand things better and practically I could use them moving forward. Like for example, just last week I went out on a date, not a first date, we’ve been going out for some time, I spoke to my therapist about it and what was really helpful was his explaining certain things about relationships, the psychological explanation of love, he called it the love triangle, and the different

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stages of dating, I like that a lot, its practical and after those type of sessions I feel like I’m taking something away practically, and have something to work with and towards, a real goal, you know what I mean? Not some pie in the sky thing.

(Yitzchak) When I first started therapy with my therapist it wasn’t a good situation with me and my married kids, with that one couple in particular, like I told you before. I really needed guidance on that issue, and still do because every so often it comes up. You know, around shabbosim and yomim tovim [holidays] when they come, v’chulu [etc.,]. What is really important and the thing that’s helpful for this issue, is when my therapist helps me understand the sugya [concept/topic] of marriage with his psychological training… even though I’ve been married for a long time, I see how things are different for kids nowadays and like my therapist once told me, what works for me and my generation, you know, how I grew up, doesn’t necessarily transfer to today’s generation of marrieds. It’s a different velt [world], and there are many things we’ve discussed that I wouldn’t have even thought of…

He never really tells me what to do, and b’emes [truthfully], I like that he doesn’t, but there are times where I am needing some explanation of why I am having such a hard time with this couple, and how to make sense of it… Also, b’oiso inyan [along the same topic], b’teva [by nature], I am a curious person, I really enjoy learning and knowledge, so every so often, either I will ask him, or he will go into some psychological idea or belief and will explain it to me. This was very

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helpful for me, especially the mehalach [modality] of CBT and that gantza sugya [all that it entails], which we chazar [review] over every once in a while. It’s very useful, and helpful for me. In a way, I think that’s what keeps me coming back and paying, because b’emes [truthfully], it is expensive, but knowing that there’s more I can learn, and I think more importantly that my therapist has knowledge about things which can be helpful for me whether it’s better understanding myself or my children is what keeps me there. Otherwise, to be honest, I really don’t think I would be in therapy this long. And probably, once I get to the point where it becomes stale, I’ll end. (Yaakov)

4.4 Highlighting strengths.

This subordinate theme discusses how emphasizing, amplifying, exploring, reinforcing, or selectively attending to a strength embedded in a situation, and not just focusing on what is wrong and how to treat it, is viewed as beneficial for the Orthodox Jewish patient.

It’s a biggie one for me. So, I would get caught up on what’s wrong, what needs to be fixed, you know? And of course, we do that in sessions. You know the explorations… But I think it’s so important to me to hear from my therapist about my positives. Really important. I think my tevah [nature/personality] is that I am hard on myself you know, I get overwhelmed easily and tend to beat myself up –

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maybe like every Jewish mother, I guess. So, it’s really helpful when she’s able to point out my strengths when my tendency is to concentrate on adversity which causes me to doubt myself and doubt how I feel about myself. You know, selfesteem kind of stuff. And at such times she is able to point out the strengths and the abilities that I have. It is really helpful for me and building my self-esteem back up. (Sara) Looking for what is right and how to help use it. That’s a big one for me really important and is really, really helpful. Big. My therapist is constantly looking, refocusing me, pointing out at what has gone well for me and not allowing me to have such a narrow focus or discussion. For example, our discussions have constantly focused on the things in my life I am proud of, my previous and ongoing achievements, and other areas I tend not to focus on or think about otherwise. Look, as an older single it’s very easy for me to fall into self-pity, anger, bitterness, and see everything through that perspective, and by her pointing out what is going right in my life and how to not only build on it but to use that in other areas, is really beneficial for me and gets me through those times. I remember it was either our first or second session and I was letting her know my history and it was all about my struggles, challenges, just so much negativity. And I remember her smiling, and gently saying in the middle of my monologue, “you know, sometimes, people come in here talking about what is not working for them. And, while that is important, it is useful to be able to talk about what is

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working for them. Can we try that for a while? And I remember having to stop and think about that it took me so off guard. Wasn’t expecting that. (Rivka) Having a good marriage, treating your wife well, at least in the way I have been taught and learnt is the yardstick for which we are judged on middos [character].

It’s like you can be a good person to the world, the community, even the mishphacha [family], but the true test is your wife. So, how do you think I think about myself being divorced? A failure, not really a good person, a fake. I walked around thinking all my relationships with people, friends, people in shul [synagogue], my Rov [Rabbi], my family, were worth nothing because I couldn’t get along with her, my wife I mean. Because my marriage ended in divorce. So, I must’ve told myself at one point, maybe came to a decision in my head or something like that, that I have no right being with people. I’d meet someone and get along fine, more than fine really, and I’d tell myself “who are you kidding?

You’re not fit for friendship, you aren’t a really good person. Your divorced, Hashem [God] has taanos [complaints/indictments] on you.” And I’d tell my therapist these things and he’d look at me and challenge my way of looking at myself and all the negatives. Just because I or others might say or think that I’m divorced, and I am a failure with marriage, doesn’t really mean I have to avoid all relationships, or am a fake and failure in all relationships and that they are not worth having. And why should Hashem think I am not worth it as well? My therapist helped me think about my divorce in more positive terms if that makes

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sense… We spent many hours and weeks looking at the things I learnt from my marriage, where I could improve moving forward, what I can build on so that my next marriage will be forever, happy and healthy. We worked out a system where he points this out. One time he just shook his head and said, “stinking thinking.”

He showed me how some of my characteristics that I thought are bad, are actually a strength, and just because others might see it as a liability, we call that into question. It might be, but it might be a strength… I think it’s a really important thing for your readers to know about how helpful this is to therapy. People should know that there are probably plenty of things about themselves that for one reason or another overlook, or that they don’t see as strengths because they have had an interpretation of them as negative. Therapy with a good therapist might be an opportunity to work on this with someone else who can see this much differently and show how it might not be so negative after all. People really have to know this. (Yitzchak) My therapist told me I am a very black and white thinker. It’s the first time I really heard such ah zach [an idea] and didn’t khop [grasp] what that meant. It’s a very all or nothing way of thinking and he explained that one of the challenges us Yidden – at least in his opinion and his experience of working with the community – has been that we think in these terms and uh, kind of apply them to our lives.

And it gets in the way sometimes of how we think about ourselves as Yidden… I was keeping track and doing really good for two weeks. And then I messed up,

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you know, had a nefillah [setback]. Got angry at my married son and his wife and came into therapy telling my therapist it wasn’t worth it. Just like that I threw out the two weeks and told him it wasn’t worth it. it grada [happened to be] was a very difficult time for me, I was pretty down about that and other things. So anyways, b’kitzur ha’maisah [long story short] we sat for two sessions that week, and he was able to point out, challenge me that most people go through their whole life without trying such an experiment, and how much he admires the work and effort I did. Also, he reminded me about ‘anu ameilim u’mekablim sechar’ [we toil and receive reward for the toiling] – that the effort itself is rewarded and that messing up doesn’t and cannot take away all the effort I did for two weeks…

I really appreciated this because it has changed the way I think about myself in many instances, and that I should be proud of my efforts and motivation… I really think that there is a place for black and white thinking in Yiddishkeit, but that doesn’t mean that Hashem also has the ability to ‘think’ lehavdil [as a manner of speech] in different terms about us. I went home that evening and told my wife about this and she was so happy and agreed that my work was worth it. She actually admitted that she did see a change in me at that time and should’ve said something to me and would do so in the future. When I think about this, I think what was really helpful was him not losing confidence in my mailos [strengths].

He pointed that out to me and that was really helpful for me not just then but

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throughout the therapy we’ve been together. It really builds one’s ah, confidence and I think is very important and helpful. (Yaakov)

4.5 The climate of hope.

This subordinate theme highlights the importance of the existence of hope that needs to exist within the therapy milieu particularly with Orthodox Jewish patient, who quite often has exhausted all resources of help before making the decision to attend psychotherapy and many times comes to treatment demoralized. Whether it’s through strengthening and empowering the patient, the therapist’s positive expectations of the patient, simply believing in a patient, reframing negative behaviors as skills, or converting a threat into a challenge, the existence and instillation of hope acts as a beneficial part of psychotherapy for the participants in that it offers a path back to a sense of possibility.

So, making the decision to attend therapy for myself was no easy choice. I literally avoided it to the very end. In fact, and this is what I was saying before which might come across as so immature, when I decided to send my son for therapy, a part of me was hoping to take advantage of that for myself. You know, like use his therapist in a way that would be helpful for my issues as well. I mean, I tried talking with my husband about some of my fears and struggles, but that just wasn’t a matzav [helpful] at all, and really, I think anyway, created more issues

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for us. I realize now, looking back I was asking him to be something he has absolutely no idea or training for, right? He’s a great man, a wonderful husband, like you said, a mentsch (smiling), but he’s not a therapist and at that time, I was expecting him to give me something which was very unrealistic. I was close with my seminary madrichaha [mentor] and spoke with her several times, but she’s in England, and again it was really not helpful and doable. So, I think my son’s therapist realized after one or two sessions that I was really needing my own therapy and she gently suggested and recommendation to one of her colleagues. I was hesitant at first, but after discussing it with my husband, who wasn’t really thrilled about the idea, although I think it was more about the additional expense he was concerned about, I made the plunge after confirming with Relief, to make an appointment. I was half-hearted about the whole thing, not really sure how it might be helpful for me. The rest is history though. Baruch Hashem [thank God], from the very first session it was such a relief for me, like a huge burden was taken off my shoulder. She’s wonderful and more importantly, she cares and believes in me, which in turn has restored my belief in myself, given me confidence, you know? It’s good. I really look forward to our sessions. (Sara) Is hope contagious? I think so. Because I experience this in my therapy. For me and my work in therapy, it has been such an important part of my emotional health. I’ve come to accept a while ago, that no one, not a therapist, family member, doctor or Rov, can magically send me what I’m needing. No one can

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find me my bashert. So, after such acceptance, what’s left? I had to ask myself this several times. I discussed it with her on many therapy sessions. And yes, my therapist agreed with me. So, what can she give me? What does therapy offer?

And she tells me that she has hope for me! She believes that there’s Something and Someone that is above this world and reality and that she believes that He hasn’t forgotten me. So, I’m handling my challenges because of the faith and confidence she has in me and Hashem. So yes, I believe it’s, hope that is, it’s contagious! (Rivka) So, I was really in the dumps when I first met with my therapist. I mean, there I was, newly engaged and already in marriage therapy! What could be more wrong!

I mean who does that? Fast forward to two years later my marriage ended, and I was in the pits. But he, my therapist stood by me every step of the way. A lot of our time was spent on looking at some of my behaviors and trying to understand them in a more helpful way. He pointed out to me for example, my understanding of moving from job to job, which I viewed as being a loser, my therapist worked with me on seeing it as being resourceful. Can you imagine? It wasn’t like this “oh there’s a silver lining type of speech” type of thing though. It took time. But I never thought of it like that. Basically, the idea of what I thought was a negative behavior, as a skill. And then we’d look at ways in which my skill is actually underused and can be used in other, more positive ways. And I’m happy to say it, my life is more hopeful now, baruch Hashem [thank God]. Don’t get me wrong,

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it’s still difficult and worrisome, but something is different about it, about me, not sure how to explain it in words exactly. (Yitzchak) During that t’kufah [period of time], I think I was really at my wits end and really had no one to turn to with this. Because of my position in the yeshiva [school] and community, I was limited with whom I can speak with when it comes to personal issues. Of course, I spoke with my Rebbi, but to be honest I think he felt a little lost too. And being able to meet a person, meaning my therapist, who was able to look at things with me in a way that gave me the belief that things can be different, that is really helpful… Not to be me’yahish [hopeless], yiyush [hopelessness] is mamish [really] the end of things. And that’s noch ah zach [another thing] I learnt that I try to give to the bachurim who come to me with their nisyonos [challenges] – you need to talk with someone who can believe that change is possible. Avadah [of course] not in a fake way, it needs to be real, but that makes a big difference. It does for me. My therapist, he’s a smart fellow, has a lot of seichel [wisdom] and the koach of sh’miya [the ability to listen and discern] and because I respect that, I respect him, his confidence in this, matters to me and means something. (Yaakov)

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Member-Checking, Journal Notes, and Researcher Countertransference During this stage of the research project addressing member-checking procedures as well as the roles of journal notes and researcher countertransference throughout the course of the interviews is deemed appropriate. The researcher set aside all preconceived experiences to best understand the experiences of the participants in this study through the use of ‘reflexivity’ (see Chapter III above), acting as the first respondent in the study prior to participant interviews, and engaging in member checking practices, effectively satisfying the IPA concept of ‘bracketing’ (Creswell, 1998). As mentioned above in Chapter III, member-checking is considered a well-established standard for evaluating qualitative studies (Rubin & Babbie, 2017) and in accordance with this practice, after the first interviews were conducted, I sent the initial descriptive, linguistic, and conceptual notes, along with emerging themes, to research participants for the purpose of validation.

This ensured that respondents had the opportunity to review the material and make note of any changes, comments, or questions they had regarding researcher accuracy and participant clarity. All four participants engaged in the process to varying degrees and were subsequently addressed during the second interviews to confirm accuracy. Overall, the research participants made very few changes and reported being satisfied with the researcher’s notes and results of their initial interview.

Sara printed out the documents and reviewed her transcription and the themes carefully, using a pen to highlight statements and to jot down her own thoughts. Overall though, she did not make any changes. She was mostly interested in ensuring that the

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information she provided didn’t give away her identity and was initially concerned that her statement about non-frum and non-Jewish therapists was too insensitive and judgmental. After much deliberation, she decided that it wasn’t and was simply an expression of her personal/subjective perspective. She stated that she was very open to the challenges others within her community might have with seeing an Ultra-Orthodox clinician but explained that this was her opinion and she had no reason to feel embarrassed about it.

Throughout both interviews I experienced Sara’s presence as engaging, serious but good-natured, and reflective in nature. She was a bit apprehensive and nervous at the beginning of the first interview, and when I mentioned this to her, she stated,

Nothing against you at all, I guess I’m a bit nervous about this and being interviewed and also, a bit uncomfortable of talking with a man. But otherwise, it was very good, and I was more comfortable as we went on. (Sara)

However, once the conversation gained traction, she appeared more comfortable and at ease. While her first interview took place in my Lakewood office, she requested we meet in her home for the second interview, to circumvent her anxiety about yichud [being together with an unrelated male in private] concerns.

Throughout the interview with Sara, I found myself feeling slightly anxious and on guard, being very conscious that I was censoring my speech and behavior, to make

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sure I not say or do anything which might make her uncomfortable. For example, I was very conscious that I hardly made or maintained extended eye contact with her. Further, there were several times in the course of the interview that I found myself wishing I could treat her as a patient, wondering what that might look like and how I might be able to help her in ways that her current therapist had not.

Rivka spent time reviewing the transcript and themes from her first interview and we spent the majority of her second interview reading through and discussing the transcription, particularly her recorded responses. Rivka modified some of her personal, identifying information. For example, I described her as “middle of the road Orthodox.”

Rivka corrected this, stating, “I’m not Yeshivish Black Hat, but I’m like Brooklyn UltraOrthodox; because I think I’m a little bit broader than Yeshivish Black Hat, but I’m definitely not Modern Orthodox.”

Both of Rivka’s interviews took place in my Lakewood office. She was very friendly, outgoing and engaged throughout both interviews, considering and responding to questions very enthusiastically. She was a bit self-conscious at being interviewed by a psychotherapist and jokingly made mention of this with questions such as “Are you psychoanalyzing me now?” Or, “Do you find yourself psychoanalyzing people all the time?” At the conclusion of both interviews she stated that the interviews had been extremely helpful and that she was happy she volunteered. She wondered aloud about how my treating patients, or my theoretical orientation/stance compared with that of her

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therapist. I found myself very intrigued with Rivka and her personality, and throughout the interview process often found myself wondering how a girl like her could still be single and her deeper struggles with meeting a guy.

From all the participants, Yitzchak took the most amount of time to review the initial notes and transcription from the first interview. During the second interview he did not make any changes or corrections but was mostly focused with the information he shared about himself. After reading and reviewing the transcript and giving it much thought, Yitzchak stated that he was “extremely happy and proud” with the material, stating that reading about himself and his narrative provided him with an opportunity to see himself from an externalizing perspective and concretely realize how much selfprogress and growth had occurred. In his words, “seeing my narrative on paper was like reading someone else’s story and really made me feel happy about myself. It gives me a renewed appreciation for my therapist and therapy experience, and confidence that things will continue to get better.”

Throughout both interviews Yitzchak was candid, vulnerable and open. At times, mostly when discussing his past, I experienced him as slightly sad and dejected. From all the participants, he presented as the most fragile and I was hypervigilant in maintaining the interview focus and not allowing our discussion to digress too much into the past. At several points during the first interview I found myself connecting deeply to his struggle and predicament, feeling really bad for him and had to hold myself back from shifting

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into therapist mode. I wonder if perhaps Yitzchak sensed this countertransference as he reported at the conclusion of the second interview that the first interview had him thinking about what his motivation had been in agreeing to this research and if he had perhaps been looking to connect with somebody who might connect with his struggle. He stated that he very much enjoyed our time together and was wondering whether he’d be able to maintain future contact.

Yaakov’s changes to the notes and themes from the first interview were minimal.

Because he did not have an email account, I hand delivered hard copies of the transcripts.

We spent the better half of the second interview reviewing the transcripts and after going through it together, Yaakov was satisfied with his original responses and was primarily concerned with confidentiality and ensuring that the information within the transcripts would not in any way threaten his anonymity. For example, he was initially concerned with the information I provided that he was a Rabbi in a rabbinical college working with young men. After thinking about it for some time, he apologized and stated he was comfortable with it and realized he was “being a bit too nervous.” He explained:

You have to understand, as much as I think therapy is important for those who need it, I still have to worry about how my being in therapy might affect my position at the yeshiva and within the community. I know we spent close to 45 minutes going back and forth about whether you should include this information

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or not, but I need to make sure I can’t be identified. I think you understand and apologize if I’m making you crazy. (Yaakov)

Considering Yaakov’s stature in the Jewish community, his reaction is entirely understandable. In fact, from all the participants, I was most surprised that he came forth and volunteered for the study. During the first interview I was conscious of containing my feelings of surprise at his agreeing to be interviewed out of fear of embarrassing him or making him feel self-conscious. Initially, I found myself slightly intimidated by Yaakov, because of his rabbinical stature and the fact that he comes across as a bit stern and no nonsense-like, and my responses to him were more dutiful than is usual for myself. Throughout both interviews Yaakov, more than all the other respondents, used many yeshivish [Jewish/Yiddish] words, terms, idioms, and jargon, and although he was very thoughtful before formulating his response to questions, he presented as very confident about his experiences.

There were times during the interviews when I worried about the conversations digressing too deeply into participants past and other unhelpful parts of their treatment or history. This created a pervasive sense of slight anxiety for me throughout the interview process, more so in the initial interviews than the second, which was spent more on reviewing the transcriptions. I was more guarded and uncharacteristically nervous around the female participants in wanting to respect and not violate any issues of modesty and yichud, and as mentioned above, switched interview locations at Sara’s request. Overall, I

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was very conscious of adapting myself to the different personalities of the participants.

For instance, in both interviews with Yaakov, in accordance with the typical UltraOrthodox code of dress, I purposely wore a white shirt and dark pants, while with the other participants I dressed as I normally do. With both males, I found myself using more yeshivish vernacular and slang or, as in the case of Yaakov, sharing Torah thoughts, while with the females, I made sure yichud, and other areas and topics of intimacy were avoided in conversation. I also found myself checking in with the female participants more often than with the males. Lastly, all participants without exception, were concerned about confidentiality, but I found the male participants to be more preoccupied with this than their female counterparts. As such, all participants requested to be interviewed during the evening hours so as not to be seen entering my office, with the exception of Sara’s second interview. Consequently, I was very conscientious of confidentiality throughout the interview process and for that reason chose to personally transcribe the interviews myself, although doing so was an extremely time consuming, tedious, and painstaking undertaking. I felt sending the recordings to a transcription agency would be challenging and inaccurate due to the yeshivish terms used throughout the interviews by the participants. And, after discussing it with my committee, was advised against using a Jewish transcriber, since it would potentially threaten the anonymity and confidentiality of the participants. Nevertheless, personally transcribing the data allowed me the opportunity of completely immersing myself in the data and participant narratives in a way which otherwise would not be possible.

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Chapter Summary

The preceding chapter organized the findings into four superordinate themes: Orthodox Cultural Touchstones; Orthodox-Syntonic Treatment Process; The Therapeutic Relationship; and The Therapeutic Factors. Sixteen subordinate themes were identified which can be seen in Table 1. Research participants provided a rich narrative of their ‘lived’ experiences in therapy which is well reflected in the data. The chapter concluded with a description of member-checking procedures and researcher countertransference. In the following chapter, these findings will be discussed and evaluated in relation to the existing research literature and theory.

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Chapter V Results The intent of this phenomenological study was to explore, identify and gain deeper insight into, the particular elements of the therapeutic experience that Orthodox Jewish patients find most helpful. Currently, the beneficial factors identified stem from the perspective of the therapist, theorist and/or researcher, despite the fact that qualitative literature suggests that patient perceptions of the therapeutic experience are of great importance to the process of therapy. The current study addresses this gap by identifying firsthand the specific features which the Orthodox Jewish patient finds useful in treatment as a means of enhancing the therapy experience for both clinicians and the members of this population they serve.

Utilizing the phenomenological methodology of Interpretive Phenomenological Analysis (IPA) developed by Smith, Flowers and Larkin (2009), the researcher was able to amass data from eight in-depth semi-structured interviews, whose findings were supported and strengthened through the use of member-checking techniques. The primary concern in IPA is to give full appreciation to each participant’s account (case), and for this reason, samples in IPA studies typically value quality above quantity, thereby enabling a detailed and very time-consuming case-by-case analysis. Following this

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recommendation, four Ultra-Orthodox Jewish participants were chosen, and data obtained was coded and analyzed using IPA guidelines, conceptually outlined in Chapter III. The study centered on the following four research questions: 1. What are the specific beneficial elements of the therapeutic encounter as experienced by Orthodox Jewish patients?

2. What about the therapy process feels helpful to Orthodox Jewish patients?

3. How did one’s Orthodox Jewish identity impact his or her subjective experience of psychotherapy?

4. How do Orthodox Jewish patients’ experiences of treatment compare with existing definitions in the current literature?

The purpose of the following chapter is to discuss the previous findings delineated in Chapter IV, in comparison with existing definitions in the current literature. Viewing and describing the data within the context of existing literature and theory, indicates a sensitivity to context, fully described in Chapter III, and is used in assessing the quality of qualitative research (Smith, Flowers, & Larkin, 2009, p. 180). Using self psychology to explicate the findings, the overarching goal of this chapter is to fully address the research questions of this study, with a particular emphasis on the final research question: “How do Orthodox Jewish patients’ experiences of treatment compare with existing definitions in the current literature?”

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The Double Hermeneutic & Hermeneutic Circle IPA aims at giving evidence of the participants’ making sense of phenomena under investigation, while at the same time documenting the researcher’s sense making, or, “how the researcher is trying to make sense of the participant trying to make sense of what is happening to them” (Smith, Flowers, & Larkin, 2009, p. 3). The synthesis of researcher and respondent perspectives and the moving between them is in keeping with, and points to, IPA’s double hermeneutic lens. The final result is thus inclusive of both the participant’s account of his or her experience in his or her own words, and the interpretative commentary of the researcher which allows for the narrative account to be engaged in several levels of interpretation. So that the analyzing and categorization of the data evolves organically from initial noting and emerging themes to the development of smaller clusters; the subordinate themes, concluding with the conceptual characteristics of each cluster; the superordinate themes. Furthermore, in accordance with Smith, Flowers and Larkin that “to understand any given part, you look to the whole; to understand the whole, you look to the parts” (2009, p. 28), throughout the process, I viewed each bit of text within the context of the whole transcript and the whole interview was thought of from the perspective of the unfolding utterances, thereby creating a cyclical approach in line with the hermeneutic circle.

As already noted in Chapter IV, analysis of the data in the interviews revealed a variety of superordinate and subordinate themes, which will be presented in this paper.

And while these themes and their subthemes contain their own degree of substance and

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significance necessary to the overall grasp of the research findings, they often overlapped in their overall objective, which was to understand the therapy experiences of Orthodox Jewish patients and better determine its beneficial factors. Consequently, while each section of Chapter V will tease the subordinate themes apart where they stand alone in relation to the literature and each other, there will be naturally occurring overlay throughout. In this way, I did not impose an artificial distinctiveness upon what was a complex data set with constantly overlapping and interrelated themes and motifs.

Orthodox Cultural Touchstones The first superordinate theme, Orthodox Cultural Touchstones, discusses how participant’s Orthodox Jewish identity make up a very crucial aspect of their personhood, gestalt and daily lives. This facet of their identity is always present, cannot be ‘turned off’ and is highly relevant to the therapeutic experience and encounter, thereby highlighting the unique intrapsychic or interpersonal considerations when treating the Orthodox Jewish patient. This theme answers the research question: “How did one’s Orthodox Jewish identity impact his or her subjective experience of psychotherapy?”

All four participants made it clear that Judaism is part of the very fiber of their selfhood and everyday lives. Sara states: “For me, religion is my being; you can’t really differentiate it.... It’s just not a separate thing. It’s the whole person.” Rivka reports: “I don’t think I went into the therapy room thinking, ‘Well I’m leaving my religious beliefs

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and practices outside the door or I’m going to make some sort of compromise if I do this therapy.’ Cause they don’t leave me. They’re my way of life, and so they’re always present.” Yitzchak states: Yiddishkeit, Torah and mitzvos, mesorah [tradition] is a part of me it’s who I am, my growth, you know my metzius [very being and existence],” and Yaakov: “It’s poshut [straightforward] to me. The halachos [Jewish laws], living according to Shulchan Aruch [Code of Jewish Law] that’s my definition of being frum [religious]. From waking up in the morning, to putting on and tying shoelaces – all al pi halacha [in accordance with Jewish Law]. That’s how it’s always been… Therapy is an extension of this for me, Shulchan Aruch, Mesillas Yesharim doesn’t cease to exist when I’m there. Whatever is discussed is filtered through this daas [knowledge/consciousness].”

From participant accounts it appears that being an Orthodox Jew and a part of the Orthodox Jewish religion is more than just an idea or a truth claim about how the world works and why it is the way it is. Rather, for these participants being Orthodox Jewish represents a fundamental part of their identity, a central part of who they are. In other words, they do not simply see themselves as having, ‘Jewish ideas’ about how the world works. This runs counter to the findings of a study on non-Orthodox participants reported

by Friedman, Friedlander and Blustein (2005) which found that for the non-Orthodox Jew, cultural identity tends to be environment-sensitive. That is, participants of that study reported viewing themselves as having two cultural identities, with one identity (i.e., as a Jew or as an American) more salient than the other, depending on the situation (e.g.,

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traveling abroad, in the therapy room) and at different times in life. Participants of this study on the other hand feel very differently. Rivka states: “In my mind it’s not like ‘I’m Rivka and I’m a Jew’, not like two separate identities or something like that – it’s one and the same, together.” Furthermore, for these participants, the strength of their cultural identity and the extent of their religious practice were consistent and syntonic. So that, all participants strongly identified as Orthodox Jewish in both culture and practice and the environment had little influence on their sense of being Jewish. Their identity was experienced as constant regardless of the company they kept or the situation they found themselves in. As Yaakov states: “Therapy is an extension of this for me, Shulchan Aruch, Mesillas Yesharim doesn’t cease to exist when I’m there.”

The idea of religion being an inherent part of one’s identity or self, as Sara states: “It’s just not a separate thing. It’s the whole person and a second to second moment to moment way of existing,” can best be understood from a self psychological perspective which posits that mature and healthy relationships involve an experience (usually unconscious) of the ‘other’ not as apart from and distinct from oneself, with a separate history and identity, but as part of, contributing to, and even constitutive of one’s own sense of self (Kelley, 1998). In other words, relationships continue to sustain narcissistic dimensions that are not regressive but are part of, and essential to, psychological development. And while the psychoanalytic literature has generally followed Freud (1927), who stressed the psychopathological meaning of religious cognition and behavior, some of the more recent literature reflect Kohut (1985) who noted that Freud

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“ignored the supportive aspects of religion (p. 261).” In a discussion highlighting the constructive, life-affirming aspects of religious experience, Rosenberger (1990) uses the term ‘spiritual self’ to indicate the persisting feelings of a relationship both to God and to religious observance, feelings that are a highly valued part of daily awareness. Poll and Smith (2003) use post-Jamesian theories to demonstrate the salience of spiritual identity on identity development and state that an implication for psychodynamic theories is that individuals may develop a sense of their spiritual selves in connection and continuity with God. From the self-psychological viewpoint therefore, religion, in part, by fulfilling the three basic selfobject needs, acts as a facilitating medium that helps the individual to form and sustain a solid sense of self (Stolorow & Lachmann, 1980) which is inclusive of a spiritual self. As Kohut himself remarked “as a supportive selfobject, religion is not poor by a long shot” (Kohut, 1985, p. 261), whose function is to “shore up, to hold together, sustain, to make harmonious, to strengthen man’s self” (Strozier, 2001, p. 328), so that religion occupies a specific position in the culture of human being, which can be related to selfobject functions. Thus, for the Orthodox Jewish patient their relationship to God and organized religion takes on additional significance, being intertwined with selfexpression and self-definition throughout intimate and public relationships, daily work life, and basic dimensions of self-esteem. And, from the self psychological perspective where emotional health is equated with the cohesion of all aspects of self, the spiritual self serves as a cohesive and central part of their self-experience.

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In sum, in considering the narratives of all four respondents, (a) Orthodox patients have a converged identity in the sense of defining their selfhood both, in terms of their religio-cultural lifestyle, and in terms of their more universal secular concerns, interests, and fund of knowledge; and (b) there is an aspect of some Orthodox patients’ treatment satisfaction levels which emanates from the ability of any given therapist and treatment to speak to this sense of their selfhood which is interwoven with their Orthodox identity. As Sara states: “I need to feel comfortable talking about issues and practices relating to Yiddishkeit [Judaism].” Lastly, (c) this spiritual aspect of their identity will inevitably play a prominent part of, and in some way impact their psychotherapy experience irrespective of the content of their original problem. For example, Yitzchak states: “I think I was hoping that doing so would avoid talking about yiddishkeit [Judaism] and such topics and just focus on therapy… And for a while that’s really how it went… It’s hard for me to locate when, but at a certain point in time in my therapy, it was like natural, like you know, it became part of our discussion… Like, certain areas of avodas Hashem [service of God], and especially trying to come to terms with and trying to make some sense of my tafkid [life’s purpose] what the Eibeshter [God] might be wanting from me.” As such, and as participants of this study indicated, one’s Orthodox Jewish identity will impact his or her subjective experience of psychotherapy and it would not be unusual for the foci or tonality of the therapy to transform over time to something apart from what the Orthodox Jewish patient envisioned at treatment’s outset.

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While the idea that a patient’s cultural identity, sensitivities and ways of thinking will impact treatment is certainly not new nor limited to Orthodox Jews, and the research literature is replete with studies highlighting the importance of culturally sensitive treatment (Hill, Vereen, McNeal, & Stotesbury, 2013; Hipolito-Delgado, Cook, Avrus, & Bonham, 2011; Holcomb-McCoy & Myers, 1999; Prosek & Michel, 2016; Matthews, Mehta Barden, & Sherrell, 2018), it is plausible that for the Orthodox Jewish patient whose religious commitment and social dynamics represents an organizing center of self, this dimension of treatment may be more amplified. Participant reports indicate that this manifests both, intrapsychically and interpersonally. Orthodox Jewish patients will need to introduce and discuss certain topics, practices and issues relating to Judaism. And because their Jewishness is so tied to their identity, a practitioners’ adverse or misplaced reaction, prejudice, or dismissal of faith/religion, or a treatment in which the environmental forces which impinge upon the Orthodox Jewish patient is underappreciated or misunderstood, can potentially be shame inducing and perceived as denigrating their very sense of self.

Well, I need to feel comfortable talking about issues and practices relating to Yiddishkeit [Judaism]. As a Jewish woman, specifically the mitzvah of Taharas Hamishpachah [Laws of Family Purity] other topics that pertain to women and family life, I need a therapist familiar with these halachos [Jewish guidelines/laws]. Also, my husband sits and learns, it is extremely important to me that I could talk openly about this with someone who gets it, you know, and

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appreciates the value and great z’chus [merit] this is. I’ve had two friends who went to therapists out of the community and the feeling they got when talking about their husband’s preference to spend many hours sitting and learning Torah for a living, was the therapist’s reaction of disregard for this value. That would be absolutely terrible if I had to go to therapy and couldn’t discuss certain topics that play a major role in my daily living and beliefs, couldn’t discuss it comfortably and without feeling misunderstood or judged or laughed at. (Sara) In summary, participant interviews highlighted that Orthodox culture is fundamental and defining, and the practitioner serving this population be cognizant of this and its impact on treatment. Attempts at treatment without an awareness and sensitivity to Orthodox Jewish culture are likely to compromise, or even preclude, successful implementation of clinically effective credibility-building or giving strategies.

Further, because the values and lifestyle of the Orthodox Jewish population are so pervasive across many aspects of the Orthodox Jewish individual’s areas of daily functioning, such misattunement can be shame inducing and quite possibly unintentionally reinforce either intrapsychic, interpersonal (or both) stigmatization.

This leads one to wonder whether it would be beneficial for the Orthodox Jew to seek treatment with a therapist who shares similar religious beliefs and cultural values?

This question will be fully explored in the section below titled “Psycho-Spiritual Integration,” but for now suffice it to say, that there is no substantiated answer that points to either direction. Simmons (2001) writes that as with any minority group, there are

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circumstances when it may be beneficial, but at the same time, they may represent a poor choice for the patient. For example, even a slight variation in religious commitments may trigger suspicion on the part of one or the other. In addition, countertransference arising from the Orthodox professional’s own unresolved religious conflicts may complicate matters (Rabinowitz, 2000). And Bilu and Witztum (1993) warn that university-educated Orthodox Jews can sometimes be hostile to their more traditional coreligionists or alternatively may be suspected by the patient of being such a “traitor.”

At the end of the day, it would seem, as Schnall (2006) notes, regardless of their ethnicity or culture it is most critical for professionals interacting with Orthodox Jews to treat them with respect and sensitivity. Greenberg states that when he questioned an Orthodox rabbi about what type of therapist was necessary for an Orthodox client, he was told, “What matters most is that he understands the religious way of life and respects each person with their outlook (Greenberg, 1991, p. 27).

Orthodox-Syntonic Treatment Process The second superordinate theme answers the research question: “What about the therapy process feels helpful to Orthodox Jewish patients?” and calls attention to the significance in which the process of treatment such as the therapy milieu, plays when working with the Orthodox Jewish patient. The Orthodox Jewish patient needs to feel comfortable and perceive of therapy as ego-syntonic and not ego-alien if therapy is to be

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helpful. Thus, the importance extended to the phenomena which comprise the therapeutic process. This section is broken down into four subthemes: 1. Religious Paraphernalia/Symbolism 2. Therapist Attire & Self-Presentation 3. Transference 4. Sense of Privacy and Confidentiality

Religious paraphernalia/symbolism.

All four participants highlighted how various religious items and symbols in the therapy room was on some level helpful in creating a climate that allowed for the unfolding of effective therapy. Sara observes that during particularly difficult moments in therapy, gazing at the pictures of holy men and women aroused a sense of calm and hope, “Like it’s a reminder of ‘Whose’ in charge.” Rivka appreciates the seforim [Jewish books] lining the bookshelves and sees it as providing a holiness to the therapy thus symbolizing, “The search for character development and growth… I do think of my therapy as a stimulus and being holy work.” Yitzchak views the scattering of Jewish magazines throughout the office as normalizing the therapy experience in that, “it makes me feel like therapy is not so different from other places I need to go like the doctor and dentist.” And Yaakov sees seforim as an extension of his therapist in that, “whatever my therapist is talking to me about is being filtered through a kosher prism – obviously not

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daas torah [word of God], but still it’s important that his words and thoughts have this foundation.”

The therapeutic effect of religious architecture, art and music is supported by the literature (Mental Health Foundation, 2006; Kehoe, 2007; Rasic, Belik, & Elias, 2009). It also speaks to the centrality of the selfobject, and Kohut’s theory clearly makes room for religious symbols in the development of the self (Rector, 2000). Kohut’s notion of selfobjects depicts the function that the ‘other’, be it persons, animals, symbols, cultural artifacts, or things, have in a person’s concrete experience of harmony, strength, firmness, vitality, responsiveness, and creativity (Lessem, 2005). And as Henriksen (2017) states, religious symbols may function in ways that help the self to develop and solidify the integration of the different elements into a stable nuclear self, and thus to widen the self’s scope of orientation. For these four participants, whether it was the mezuzah, seforim, gedolim pictures, or some other symbolic investment of God, from a self psychological vantage point, it was deemed helpful for the self’s own purposes, and contributes to a climate which is safe, empathic, and affirming enough to guarantee that emotional arousal can be tolerated and addressed. In this way, Orthodox Jewish patients can let go of strict censorship around expressing their feelings.

Therapist attire & self-presentation.

Similar to the previous subtheme discussing religious paraphernalia, for all four participants, something about the therapist’s self-presentation, whether in the form of

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dress or language, was viewed as helpful to the therapeutic relationship in particular and overall process of therapy in general. Sara views her therapist’s overall demeanor and “being,” both in speech and dress as a major factor in her positive therapy experience.

“Very calm and soft-spoken, very soft-spoken, which I really like. And her whole, what would you call it? Her ‘being’, how she dresses… it makes it so easy to trust, to talk to her because there’s a shaichus [connection] there, a Yiddisha shaichus [Jewish connection] not just a professional one, you know what I mean?” (Sara) For Rivka, her therapist’s balanced mode of speech “between professional and Jew” contributes to her level of comfort in the therapy room. She states: “What I like about her [my therapist] is the nice balance of how she talks, you know, kind of like a balance between a professional and Jew, not too much on the yeshivish terms, but at the same time most definitely not some professor in college (laughing). Yes, makes the therapy comfortable and inviting for me. I understand her, and she understands me, because we talk the same familiar language, if that makes sense.” (Rivka) Yitzchak sees his therapist’s manner of dress as non-conforming, a characteristic and confidence he desires for himself. He states: “And he doesn’t conform, wears colored shirts, nice shoes and is totally okay with it. He’s confident and I’d say proud of who he is and what he accomplished – that is something I dreamt about for the longest time.” (Yitzchak) While for Yaakov, his therapist’s self-presentation, both in dress and language provides a certain degree of comfortability, “But baruch Hashem [thank God], he looks like a yeshivisha fellow, ich veist nisht [not really sure], like a middle aged yungerman [learning fellow], you know?

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Probably early 50s b’erech [approx.], dresses like ah yeshiva mahn, like unz’erur [one of us], with a short-trimmed beard and his tzitzis [fringes] out. I grada [happens to be] try not to judge people on what they are wearing, anybody can wear what they want, ohbur [but] for me personally, I feel comfortable when it’s yeshivish. It’s the language, someone who fahrshteys [understands]. I don’t know, makes me feel at home.” (Yaakov) As can be seen from participant accounts, from the moment patients first come into contact with their therapists, they are involved in an ongoing process of searching for cues and clues about them. In the absence of concrete biographical information, the therapist’s personal appearance, including dress, language and immediate environment, are the only source of information available. Consequently, participants tend to scrutinize appearance in an attempt to get a sense of who their therapist is, how professional they are, and how likely there is going to be a goodness of fit for the creation of a trusting and helpful relationship.

The research literature corroborates these findings as well. In a paper by King (2018) exploring the role of therapist self-presentation from an attachment perspective, participants’ assessments of how professional, competent, trustworthy and containing their therapists were, seemed to be influenced by the therapist’s attire and appearance.

King’s findings suggest that the therapist’s appearance plays a central role in the therapeutic relationship and attachment process, both on a conscious and unconscious level. Specifically, patients seek to attach to the therapist in order to promote emotional security (Mikulincer, Shaver, & Berant, 2013), and that for therapy to be effective there is

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a need to develop trust and a sense of felt security within the dyad (Beebe & Lachmann, 2014). Part of this process includes the search for safety, which for many patients tends to involve seeking qualities in their therapist that are similar or familiar to them, such as therapist dress and attire, which are equated with professionalism and level of skill.

And how might self psychology view this matter of therapist presentation and attire? It seems that for all of the four participants, on some level, being in the presence of, and connected to, a therapist who was perceived as sufficiently alike, whether in appearance or language, fulfills the twinship/alter ego selfobject need, which is a precondition of all selfobject experiences. Eisenstein (1988) conceptualizes the twinship concept as pertaining to the integration of the affective experience of “resonance of alikeness” with another and which serves as a vital component of creating a sense of belonging. For Yaakov working with a therapist who dresses and speaks “like unz’erur [one of us],” allows him to feel a sense of belonging, of being “at home” in the therapy.

And while the concept of twinship does not exhaust the complexity of the belonging phenomenon insofar as there may be aspects of mirroring and idealizing selfobject experiences that also relate to belonging, Rector (2000) points out that Kohut (1984) confined his discussion of ‘belonging’ to the twinship selfobject. In other words, there is a specific sense of security and of belonging that cannot be explained in terms of a mirroring response or a merger with ideals (p. 200). Perhaps this is best captured Basch (1992) who uses the term kinship when describing Kohut’s understanding of twinship:

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I prefer to call this the “kinship experience” because it asserts and strengthens the sense of being a member of a group – the acceptance that comes from “being like” the other (p. 17).

Yitzchak expresses a selfobject longing to experience an essential likeness with his therapist, which he dreams about and hopes he’ll be able to discover within himself.

Finding oneself in the other and vice versa constitutes the most essential facets of humanization and belonging.

I remember thinking how much I’d be giving up if I go somewhere else out of the community. This way, I mean sitting each week with a frum guy, good hashkafos [ideals], uh, you know yarmulke [skull cap], ben Torah [learned Jew], able to juggle both his professional and Yiddishkeit – you know that’s really what I’m needing!... And he doesn’t conform, wears colored shirts, nice shoes and is totally okay with it. He’s confident and I’d say proud of who he is and what he accomplished – that is something I dreamt about for the longest time. I’m really happy I decided to stay with him and stick with it. (Yitzchak) Rivka’s emulation of her therapist’s mannerisms and speech oddities allow her to feel similar to and connected with her therapist, and her self appears to be sustained by her therapist’s presence and self-presentations.

I guess there’s a part of me – the teenage part of me I guess you can say, that just really likes and looks forward to being with her. Oh gosh, I hope this isn’t weird (smiling). But its honest, the truth. (Rivka)

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As pointed out in the previous section and elaborated upon in Chapter II, the Orthodox Jewish patient may come to therapy with negative internalizations and stigmatizations. And while these might be somewhat mitigated through treatment with someone from outside the community and faith, research participant narratives corroborate Kohut’s contention that negative or difficult experiences of alikeness may be preferable to more positive experiences of support from those who are experienced as too different (Rector, 2000). Participant narratives suggest that working with a therapist whose self-presentation is similar to one’s own, may be helpful in that “support of the self is derived as much (and sometimes exclusively) from “nonverbalizable experiences of sameness, of identity as from the receipt of actual help (Kohut, 1984, p. 227).” So that through the satisfying of twinship selfobject needs, at the very moment in which the Orthodox Jewish patient might feel apart, distant, different or alienated from their community, the therapist’s self-presentation and attire may allow the patient to experience feeling acknowledged as a fellow human being, and connected to a similar other, which facilitates a sense of connection and belongingness to the larger community.

Summary.

This section and its preceding one, highlighted how the relationship between self and its different selfobjects plays a crucial factor in any development of the self and had clear implications for all four research participants. While an expression of the nature of God/religion in the form of cultural symbols, pictures, books, or the dress and speech of

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the therapist may appear to one person to be no more than a statement of assumed facts with no clear significance, for the participants of this study it clearly functions as a selfobject and positively impacts the process of their therapy. In addition to its religious significance and role, such symbols, as the preceding sections demonstrate, serve additional psychological functions as well, and should be seriously considered if we are to provide a beneficial therapy experience to this population.

Consequently, there are many seemingly trivial details that may help Orthodox Jewish patients feel more comfortable in therapy sessions and contribute to a positive therapy experience. For example, Bilu and Witztum (1993) describe the location and decoration of their clinic, both intended to make the environment seem less alien to their Orthodox clientele. Probably even more critical is that all visible staff members abide by a modest dress code. This is especially important for female clinicians, who should avoid apparel such as short skirts and sleeveless or low-cut shirts. The Orthodox Jewish patient, like every psychotherapy patient, enters into the therapeutic relationship with a mixture of dread and hope, which is why the trappings of cultural competence are important – the books, pictures on the wall, mezuzah on the doorpost, all of these might inform the patient whether they have come to the right place and demonstrates an understanding of the psychological contribution religious symbols provide. The manner of therapist dress and speech are likely to have an impact on the development of the relationship with Orthodox Jewish patients more so perhaps than with the non-Orthodox Jewish patient and should not be minimized nor ignored.

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Transference.

This subordinate theme calls attention to the existence and role that transference plays in the process of therapy. While the definition and conceptualization of transference varies in accordance with one’s theoretical framework, participant narratives all indicate the presence of transference, thus implying that it may serve to enhance the overall process of treatment, not only for the secular psychotherapy patient but for the Orthodox Jewish patient as well.

Ever since Freud’s original formulation, transference has been a pivotal concept in psychodynamic therapy. In this study as well, from the four participant narratives it appears that there was a transferential experience which contributed in a beneficial way to the therapy process. For some participants, such as in the case of Sara, the transference appears to be more in line with the classical conceptualization and with others, such as Rivka, Yitzchak, and Yaakov more aligned with a self psychological conceptualization.

Sara appears to experience an unobjectionable (maternal) transference (Auchincloss & Samberg, 2012) with her therapist. Sara states: “It’s like I’m talking with my Bubby [grandmother] at times, I have a real affection that I developed for her!” This type of transference is positive and helpful because in Freud’s conceptualization it does not function as a resistance. Freud (1914a) contrasts this with an erotic positive transference, in that the positive unobjectionable transference is more about nonsexual positive feelings for the therapist, which the patient feels free to express. Sara describes how her affection played out in treatment in the form of bringing her therapist cookies:

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I’ll tell you something interesting. There was this time, around Chanukah I think, when I was baking in the kitchen and for some reason, I found myself thinking about how my Bubby and I would talk and eat cookies together. It was a spontaneous thing, I just started baking cookies and brought them to my therapist at our next session. I know it sounds so weird, but it was such a great feeling, talking with my therapist over cookies, the same way I used to with my Bubby!

(Sara) Freud opined that because this unobjectionable transference includes positive regard for an authority figure, it can be viewed as a component of suggestion, or, the therapeutic benefit of the therapist’s influence. It is because of this influence that the patient is more likely to accept the therapist, their explanations and interpretations. The nonthreatening positive regard of the unobjectionable transference also allies the patient with the therapist and supports the patient’s motivation to remain in treatment despite the possible shame and frustration attached to the therapy experience, which, as discussed extensively in this paper, has particular relevance for the Orthodox Jewish patient. Sara expresses this feeling when explaining why she feels more receptive to her therapists advice or guidance regarding marriage: “it makes things so much easier to accept and do – I imagine she has a lot of wisdom from her own life, you know her marriage and balancing being a mother and wife and think that’s why it’s so easy to converse with her.”

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From, Rivka, Yitzchak and Yaakov’s narrative as well, we detect a transferential experience occurring within their respective therapeutic processes. Rivka states: She probably was one of those girls that sailed through high school and life – popular, lots of friend because she has a great personality, I’ve always envied those girls, you know, just wishing I could feel so comfortable with myself – and now, I get to see and have a relationship with one every week! I’ve always envied those girls, you know, just wishing I could feel so comfortable with myself – and now, I get to see and have a relationship with one every week!... There are times when I find myself using words or phrases she uses, or even hand movements.

(Rivka) Yitzchak states, “Uh, most definitely not someone I know or knew. But I’ll tell you this much, b’emes [in truth] he’s someone who I dream I could be like.” (Yitzchak) And in the case of Yaakov: I think he has yi’shuv ha’daas [clear thinking] and menuchas ha’nefesh [sense of serenity], you understand what I mean?... When you meet with him, there’s epes [something], I don’t know, a calmness, you know? Like things are b’seder [in order/altogether] by him… Something about him my therapist, maybe it’s his calm voice and always appearing calm, never rushed or stressed, it’s something like that… I like it. It’s very good. That mailah [strength] of never feeling rushed, always seeming to have a sense of menuchas ha’nefesh [peace of mind]. Speaking slow and thought out, like everything in his life is b’seder, just in order, you

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know? So, I guess you can say that I’m me’kaneh [envious of] my therapist (smiling), this pr’at [aspect/detail] and mailah [strength] of his personality is something to work towards for me. But it’s nice to see it each week… It’s good to at least see it in action, you know, when I’m with him. (Yaakov) In contrast to Sara, these three participants have transference experiences which appear to be organized around the self-selfobject matrix. Their narratives indicate aspects of both, idealizing and twinship selfobject transferences. This is mixture is not uncommon. Lessem (2005), in a discussion on the selfobject transference, posits that the selfobject experience is inevitably mixed, that is, composed of more than one type of selfobject experience. Mirroring, idealizing, and twinship experiences are conceptualized as always interwoven. In every idealizing and mirroring experience, some of the other is present. In order for mirroring to be vitalizing, it must be experienced with someone at least a bit idealized. Likewise, in order for idealizing to be experienced as self-enhancing, the idealized person needs to be viewed as implicitly affirming. The selfobject experience of essential alikeness that is at the core of the twinship experience involves a background of affirmation (Fosshage, 1997).

In treatment, the therapist, similar to the early caregiver, serves multiple selfobject functions (Rowe & Mac Isaac, 2004) and an important aspect of treatment is identifying these selfobject transferences within the therapy process as they develop. Both Rivka and Yitzchak indicate a need to feel linked to an admired other, and to merge with or feel close to someone they are confident in. Yitzchak is hopeful that being linked to an

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admired, well-balanced therapist will somehow “rub off,” on him and positively inspire his life. “I kind of wish that were me, my life. That’s why I like going to see him, at least I have a part of it weekly and who knows, maybe it’ll rub off (smiling)!” Rivka finds herself emulating her therapist’s mannerisms, thus allowing her to feel affiliated with and share an “essential likeness” (Kohut, 1984, p. 194). This expression or sense of similarity with her therapist benefits her treatment process and as she reports: “I guess there’s a part of me – the teenage part of me I guess you can say, that just really likes and looks forward to being with her.” For Yaakov, partaking in a treatment with an idealized therapist figure who exudes calmness, serenity or, “menuchas hanefesh,” brings a sense of cohesiveness and organization to his internal disorganized state and is something he holds in high regard. In his own words: That mailah [strength] of never feeling rushed, always seeming to have a sense of menuchas ha’nefesh [peace of mind]. Speaking slow and thought out, like everything in his life is b’seder, just in order, you know? So, I guess you can say that I’m me’kaneh [envious of] my therapist (smiling), this pr’at [aspect/detail] and mailah [strength] of his personality is something to work towards for me.

(Yaakov)

Summary.

For all participants, transference unfolded and was a salient aspect over the course of their therapies. Whether conceptualized as classical or self psychological, this theme

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emphasizes that transference cuts across all treatments regardless of whether the patient identified as Orthodox Jewish or secular. And while the concept of transference emerged from, and is embedded in, psychoanalytic and psychodynamic psychotherapies, the findings from this study are suggestive that even clinicians practicing from nonanalytic traditions such as cognitive behavioral therapies, might benefit from developing an awareness into how transferences of different types may be effectively responded to or dealt with since it can positively relate to therapy process. Transference provides us with an information rich window into what the patient might be desiring and what they wish to avoid and can be used as a therapeutic tool to promote self-understanding and healing.

For the Orthodox Jewish patient in particular, transference can be used to better understand the function of religious experience for a patient, and as Jones (1991) indicates, “changes in the therapeutic transference ought to be paralleled by transformations in a person’s religious experience (p. 10),” so that the function of religious experience develops congruently with the person’s self-development.

Sense of privacy and confidentiality.

It comes as no surprise that a pervasive sense of privacy and confidentiality was emphasized by all participants, as being crucial to the overall positive process of their therapy experience. This is consistent with the literature on the subject of confidentiality and the Orthodox Jewish psychotherapy patient, in that the concern about confidentiality has been identified as one of the two greatest barriers to service use for the Orthodox

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Jewish patient (Loewenthal & Brooke-Rogers, 2004). Being known to use mental health services is particularly discrediting/stigmatizing for members of the Orthodox Jewish community (Loewenthal & Brooke-Rogers, 2004; Cinnirella & Loewenthal, 1999), implicating the importance of creating a milieu in which the Orthodox Jewish patient does not fear a breach in privacy or that personal issues will be disclosed to others within the social circle. This cultural insistence of placing a premium on secrecy, makes protecting and being vigilant about confidentiality all the more necessary when dealing with the Orthodox Jewish patient than perhaps the secular one, and the ability of the therapist to convey a sensitivity about, and understanding of the importance of maintaining privacy allows for a sustained positive therapy process. Whether it was the fear of being seen entering or exiting the therapy office, the sharing of information with others, or meeting the therapist outside the treatment milieu, all four participants expressed an initial concern and fear about matters related to confidentiality. Sara describes a profound sense of shame, stating, “I think I’d want the ground to swallow me,” at the prospect of meeting someone or being recognized while going/coming from therapy. She explains that for her good therapy “is not only about actual talking, but also about the experience, and for me having a security of confidentiality is so important.” Her therapist’s attunement to this fear and enacting precautionary measures allows Sara to feel “protected, and taken seriously,” in that her therapist understands the point of view from the perspective of the patient and what it’s like within the Orthodox Jewish community.

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There are two entrances for her office one for when you come and the other when you leave. I really, really appreciate that. (Sara) Rivka raises a similar but slightly different concern. “There’s something about being heimish [Jewish over-camaraderie] that really bothers me when it comes to the frum professional world. It’s like almost a given, at least from what I’ve seen so many times, even in my own work at the office. It’s like a given that information tends to be shared, because of the haimishness [over-familiarity] that exists in our small knit community. I really hate it.” (Rivka) ‘Heimish’ or ‘haimishness’ is a Jewish term which loosely translates as overfamiliarity. In the context of therapy, it refers to an Orthodox Jewish therapist who, due to the insular and tight knit nature of the community might be enmeshed with its members resulting in potential inadvertent compromising of patient privacy. Understandably, this dynamic of haimishness, can be a real impediment in the treatment process. And for Rivka, only a chance encounter of meeting her therapist in the market, allowed her to feel “secure and reassured” in that her therapist can be trusted.

Yitzchak’s concern highlights a different angle, namely how the sensitive material from his sessions might have repercussions for his family. “I really don’t care whether or not people know I am in therapy, I think the fact I’m divorced anyway people expect it. I’m sure people near the office see me going in week after week, but I really don’t care about that. But what I discuss with my therapist, you know, the actual discussion, that needs to be protected for me and for my family.” Yitzchak recalls feeling thankful that his

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therapist took the time explaining the guidelines surrounding confidentiality at the beginning of his treatment.

I think that at the beginning of our therapy, maybe the first or second session, he actually spent some time explaining to me how important privacy is and I remember feeling thankful that this was going to work because I really was so scared about this. (Yitzchak) Yaakov’s concerns are similar to his fellow participants, “My biggest concern was being found by someone that I am going to therapy, and what they would think.” Having a therapist who was sensitive and open to discuss confidentiality concerns as they arose in the treatment, conveys a sense of trust which ultimately allows him to feel calm and enhance the therapy process.

We actually went through some of the halachos [laws] together also. I once mentioned this to him, I think I called him a mentsch, and he told me that in addition to the halachos involved, he was under some sort of law, legally, that didn’t allow him to discuss our sessions with anyone or anybody else’s with me. I liked that. Makes my therapy so much calmer for me. (Yaakov) While confidentiality and protection of privacy is of high importance to all patients of psychotherapy, for the Orthodox Jew however, there appears to be a hypervigilance, which, to an outsider of this community, might seem to border on paranoia and the irrational. Why is this so? As elaborated upon previously in Chapter II, the Orthodox Jewish community often attaches a stigma to individuals receiving mental

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health services. Previous reports attribute this to the strong family-centric value system operating within the Orthodox community (Margolese, 1998; Loewenthal & BrookeRogers, 2004; Schnall E. , 2006). Of specific importance is the stigma among Orthodox Jews that often focuses on the perceived consequences of mental illness to family functioning, stability, and children. Consequently, the stigma of mental illness often extends to siblings and children of the individual, since they are perceived as being highly affected. These aspects of stigma can also negatively affect marriage prospects, as dating within the Orthodox community is often prearranged after an investigation of family and personal background by both sides (Rosen, Greenberg, Schmeidler, & Shefler, 2008). The resulting loss of social status may lead to avoidance of individuals with mental illness and their families. Given these unique cultural factors, it is more understandable why the Orthodox Jew might be obsessive about secrecy more so than the typical secular patient.

Lastly, several authors have described the Orthodox Jewish individuals’ wish to see themselves as the ‘perfect Jew’. The Orthodox Jewish woman wants to see herself as the perfect baalabusta (woman of the household); always cheerful, warmly welcoming and hospitable, immaculate home with well-behaved, healthy children who are well developed spiritually, morally and interpersonally. A woman who runs the home and supports the family, while enabling her husband to engage in prayer and religious study.

The Orthodox Jewish man hopes to be a model of spirituality and stability for his family.

Whether it’s engaging in religious study or giving charity, he sees himself as deeply

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connected to God. Wise, calm, and rational, and providing a sense of tradition and direction for his wife and family so that he can be a link in the long chain of mesorah [religious ancestry] (Loewenthal, 1998; Goshen-Gottstein, 1994). It can be hard therefore, to admit to deviations from this ideal, and making the decision to seek therapy often entails courage combined with a heavy dose of desperation.

From a self psychological view, the Orthodox Jewish individual enters treatment with a deeply painful feeling about their self. Often, what makes shame so painful is that the patient has experienced humiliation at the very moment he was fervently hoping to shine in the eyes of the other (Lewis, 1971). A therapeutic environment which emphasizes a sensitivity towards privacy and confidentiality protects and preserves the self from further humiliation and allows the patient on some level to have his/her wish for approving attention, sympathy, and understanding met. Preserving and protecting privacy and confidentiality is therefore essential for the successful treatment of the Orthodox Jewish patient.

Summary.

In sum, the preceding section highlighted how a treatment that is vigilant in ensuring, safeguarding, and maintaining confidentiality is viewed by the Orthodox Jewish patient as enhancing the treatment process. It is of high importance therefore, for clinicians treating this population to acknowledge and validate a patient’s sense of stigma, thereby limiting the shame factor and preserving their sense of self. Making the

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decision to attend therapy is likely to produce feelings of hesitancy and discomfort for the Orthodox Jewish patient, especially in the initial phases of therapy, and it is imperative that the clinician be mindful that this might likely persist to some extent for the entire duration of therapy (Safran & Schlosser, 2013). The findings of this study are supported by the research literature (Wikler, 1986) which cautions therapists to expect an unusually strong attentiveness to confidentiality on the part of the Orthodox Jewish patient, perhaps more so than the average psychotherapy patient. Moreover, practitioners need to appreciate the great resistance and risk that the Orthodox patient overcame in seeking therapy and not mistake his or her behavior for paranoia. As underscored by participant narratives above, for the Orthodox Jewish patient, community stigma and the clear dire societal repercussions are real, which accentuates the primary need for confidentiality coupled with an understanding of what may occur should the patient’s attending treatment were to become public knowledge. This extends to the individual, his/her family, and their future which includes marriage prospects.

Based on these findings, there are several considerations and specific measures which clinicians working with this population might want to bear in mind as it pertains to confidentiality concerns: 1. Sublette and Trappier (2000) recommend refraining from scheduling two Orthodox Jewish patients consecutively. This study comes to a similar conclusion. It would be judicious not to schedule Orthodox Jews for consecutive sessions, because they may be uncomfortable meeting a member

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of their community in such a location. Having a two separate entrances for those coming and those leaving (as Sara’s therapist implemented) would be optimal.

2. Bilu and Witztum (1993) suggest a general flexibility with appointment times as a way to increase compliance when dealing with members of this group, who may be ambivalent about attendance. Once again, this study comes to a similar conclusion with the added caveat that ambivalence for the Orthodox Jewish patient may stem from shame and not simply a push/pull between wanting and not wanting to change.

3. Lastly, before encouraging patients to speak about their challenges with friends, relatives, or to join support groups, clinicians need to mindful and sensitive to the reality that doing so may adversely affect their standing in their community (Paradis, Friedman, Hatch, & Ackerman, 1996). And as mentioned, might make it difficult for them to find suitable marriage partners.

The Therapeutic Relationship The third superordinate theme is titled “The Therapeutic Relationship� and calls attention to the importance Orthodox Jewish patients attribute to the therapeutic alliance, which includes therapist traits and characteristics as well as the strength of the affective bond and link. No matter how knowledgeable and technically skilled a therapist is, absent

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a strong therapeutic relationship with the patient, even the most powerful methods may prove ineffective. This super-theme is captured by Lazarus who states, “The therapeutic relationship is the soil that enables the techniques to take root (1984, p. 493).”

This section is broken down into three subthemes: 1. Empathy 2. Sense of Equality 3. Going the Extra Distance

Empathy.

Remarks made by all four participants highlight the importance and beneficial role empathy plays within their respective treatments.

And her reactions are just loaded with the feeling that she really gets what I’m saying… Uh, how can I explain this better? I’m not talking about knowledge, the type you get from reading books, parenting books and stuff. I’m talking about my feeling that she’s really a part of my experience – cliché but like walking in my shoes. And it makes me feel so calm afterwards… I felt so understood… Unless you experience this, it’s difficult to explain and understand. (Sara) The ability of Sara’s therapist to observe in an empathic way, allows Sara to feel that her therapist is immersed in her experience which makes her feel understood and is deemed helpful.

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Rivka attributes her therapist’s overriding compassionate and caring way of being as helpful in that it allows her to tolerate the inevitable ruptures which occur in the course of her treatment.

I think she’s super compassionate. She cares. Simple as that. This is especially important for me. Listen, there were plenty of times when I didn’t appreciate some of the things she said or recommended. And there were several times I was upset at her behaviors – like the time she scheduled me and forgot about the session because it was her lunch break – but you know what, I think her overall way of being with me, outweighs this for me. It’s like I feel anger or something, and then there’s another part of me that is able to tell myself that overall, she’s really caring and is there for me. (Rivka) In Yitzchak’s case, his therapist’s empathic response allows him to enter into Yitzchak’s world which in turn allows Yitzchak to feel understood, connected and accepted by his therapist.

I really believed I was beyond help. I mean, how could a therapist exactly help me? There’s no solution for my struggles. It’s not like he can offer me some advice that will help with things. You know what he said? He told me, “I know I can’t solve this for you. But I can and will make every effort to share in your struggle and pain.” And I remember I began to cry – one of the only times in my life. I’m not talking teary-eyes, full blown crying. And I never felt so close to someone than that time. It’s one of the main things that has been helpful for me

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because from that moment on, I felt able to share. And I know he doesn’t and can’t agree with my thoughts or ideas, but he allows me to at least talk about them in the open without having to pry or pull teeth. Just by being accepting.

(Yitzchak) Similarly, the empathic reaction of Yaakov’s therapist to his story was helpful and represented a turning point in his treatment. This allows him to overcome his resistance and initial suspicion by acknowledging that his therapist is “emesdica [genuine], it’s not just about money. He really cares and feels for his patients.”

I’ll tell you what’s really good about him [my therapist] he’s an emesdica mentsch [honest/genuine human being]. I’ll tell you a story which to this day I am still working towards, but which really made a roishum [impression] on me… We were talking about looking back at life and the idea of regrets – in life in general, as a parent, and as a yid [Jew] and some of the other responsibilities I play. And I was telling him how difficult it was for me to have to accept some of my children’s choices and decisions and how many hours I spend davening for siyata di’shmaya [divine assistance] in chinuch habonim [raising children], right? So, I’m talking, and as I’m talking, I’m looking at him and he’s mamish [really] almost crying. There were tears in his eyes. And I stopped. So, he realizes I stopped, and he asks me about it. I tell him I’m reminded of the story of Rav Moshe who began to cry when a mother came to him for a sh’aliah [question] for a serious p’sak [decision] about a medical procedure and she came with her

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doctor and Rav Moshe began to cry after hearing the story. It was powerful and really affected me. I told him that I wish I could be like that and have been working to get to that madreigah [level]. But it made me think of him in a whole different light after that. (Yaakov) There are several reasons why self psychology views empathy as central to the therapeutic process. Firstly, empathy acts as “a definer of the psychological field” (Kohut, 1959) or the means by which the psychological observer gathers information about the inner world of human experience (Siegel, 1996). In this way, empathy acts as a mode of clinical observation, and main way of understanding the experience of another.

From the patient’s stance, being on the receiving end of empathic understanding, fosters an effective clinical process (Sorter, 1999), promoting safety, acceptance patient selfexploration.

Secondly, in what Siegel (1996) refers to as the empathy paradox, although not a therapeutic act, empathy somehow carries a broad therapeutic effect. The experience of being empathized with, that is, empathy as a mode of responsiveness, allows the patient to feel understood in a way that helps him to feel connected to the therapist and others.

Siegel explains this phenomenon as the presence of empathy acknowledges the existence of the other and affirms their humanness. Having an experience where one feels recognized, accepted, and understood inevitably helps the patient to become more selfaccepting. In the words of Rogers, “if a person can be understood, he or she belongs (1986, p. 129).”

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In this way, it appears from participant accounts that both aspects of empathy were manifest and deemed helpful. Sara states that being in a therapeutic situation where she was able to observe her therapist operating from a place of empathy is cathartic and allows her to feel that, “she’s really a part of my experience,” and “she really gets what I’m saying.” Rivka is more concise, “She’s super compassionate. She cares. Simple as that.” Although unable to verbalize exactly how and in what way, Rivka’s experience illustrates the benefit of being on the receiving end of her therapist’s empathic way of being.

Yitzchak’s therapist’s statement, “I know I can’t solve this for you. But I can and will make every effort to share in your struggle and pain,” corroborates Kohut’s view that empathy is more than a method of clinical observation, rather it also serves as “a powerful emotional bond between people” (1984, p. 84). Something about that response was extremely validating to Yitzchak’s psychological-emotional existence and allows him to open up and connect with his therapist in an exceptional way.

The empathic immersion exhibited by Yaakov’s therapist, causes Yaakov to “think of him in a whole different light after that. This is a man who is emesdica [genuine], it’s not just about money. He really cares and feels for his patients. You can’t fake that right? You just can’t.” This is in keeping with the research on empathy which found it to be a key indicator of a therapist’s ability as a facilitator in the therapeutic relationship (Moore, Meyer, & Viljoen, 2017; Tolan, 2007)..

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The curative force of empathy has long been acknowledged, and its importance within the clinical setting cuts across all theoretical approaches. Feller and Cottone (2003) cite a plethora of studies indicating its importance as one of the key components across numerous theoretical approaches including psychoanalytic, object relations, selfpsychology, client-centered, existential, psychodynamic, gestalt and behavior therapy, as well as cognitive, cognitive-behavioral, rational emotive behavioral and relational therapies. Identifying empathy as one of the beneficial aspects of therapy is not limited nor unique to the Orthodox Jewish patient and research studies have shown that psychotherapy patients “viewed empathy as integral to the personal and professional relationship they had with their psychotherapist� and believed that empathy from their psychotherapist benefited their psychotherapy sessions (Macfarlane, Anderson, & McClintock, 2017).

Summary.

Empathy is one of the fundamental concepts in self psychological theory and practice and in his final definition of the term, Kohut called it “the capacity to think and feel oneself into the inner life of another person (1984, p. 82). Whether as a mode of observation or responsiveness, all four participants deemed having a therapist who provided an atmosphere of empathy as an important and beneficial factor of their treatment. Participants reported how feeling empathized with, allowed them to invest in their therapist, and how sustained empathy was a factor in maintaining the therapeutic

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relationship even in the face of inevitable disruptions. And while an atmosphere of empathy remains important, it is only one piece of the process which fosters a supportive environment and therapeutic relationship. Which leads us to the next identified factor, sense of equality.

Sense of Equality.

All participants reported that an egalitarian relationship in which the dynamic with their therapist was perceived as being balanced and respectful rather than superior/inferior, was deemed beneficial. In one way or other, participants described their initial anxieties about the therapy situation being conceived as authoritative or doctor/patient, an image of the detached therapist exuding an impersonal, dominant, allknowing, outlook with a broken, weak, crazy patient. With time however, whether through therapist way of being, interaction, or certain defining moments such as Sara’s therapist asking for a recipe, these initial perceptions were altered, and participants appreciated and valued the humanness, balance, and reciprocal exchange of the therapeutic relationship.

To illustrate, Sara acknowledges initially feeling threatened by, inferior to, and consequently “resentful� of her therapist, So, in the beginning, I felt very self-conscious. Here I was talking about feeling like a failure as a mother and wife, as a person. And she seems to have it all together. Like a successful career, sane home life and family. I think I felt like

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“yep, here I am, not as good as you. Yes, you’re better than me. You’ve got it all figured out, I’m lost.” I’ll admit it, I was a little resentful. (Sara) Her therapist’s partaking in and enjoying her hamantashen and then asking for the recipe assisted in establishing a “normalizing” dimension to her treatment, allowing Sara to feel valuable and conveying the message that though her therapist might be wise she was not necessarily looking down at her.

One time, I brought her hamantashen [type of pastry] right before Purim, and she liked them so much she asked me for my recipe! It was like she was telling me that I have what to offer in this relationship as well. And that it wasn’t she who was judging me, it was me who was judging me. (Sara) Interactions that were characterized by other participants as helpful included, being viewed as a three dimensional person, or “not simply viewed as an ‘older single’ or being more than just pity case,” (Rivka) or, as Yitzchak indicated, feeling “like a human” by being accepted and treated as an “equal,” and lastly, just two people dialoguing together as one human being to another, or a “shaklah v’taryah” [give and take].

My therapy is a shaklah v’taryah [give and take]. I like it that he, my therapist, doesn’t make me feel like I’m meshugah [crazy]. He asks me questions about certain things and listens. Several times he’s asked me the mekor [source] for certain halachic rulings or which sefer he can find them in. Sometimes he will write it down, some of the ideas I tell him. I feel like he respects me and doesn’t

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look down on me, like he’s the doctor and I’m like an am haaretz [ignoramus].

(Yaakov) Although the concept of an equal relationship between a therapist and a patient is often attributed to Rogers (1988) and associated with the client-centered psychologies of the 1940s and 50s, in truth the idea originated within the psychoanalytic tradition established by Freud. Despite the emphasis on the tabula-rasa/blank screen therapist model, Freud, as opposed to many of his contemporaries, took seriously all the anxieties, disturbances, utterances, and dreams his patients experienced and was truly receptive to their inner world, implicitly conveying the importance of establishing a relationship which respects the patient. Expanding upon this implicit message, Jung (1979) suggested that therapists see patients as equals, should abandon all preconceived opinions, methods and diagnoses, approach each case as unique and not assume to know better than the patient. Ferenczi took this idea to the extreme by engaging in his experiment of mutual analysis (Ferenczi, 1932).

And while valuing a therapist-patient dynamic that offers a sense of equality might not be exclusive to the Orthodox Jewish patient, it may be more of a prerequisite and crucial than with the general population. As mentioned throughout this paper, seeking psychological treatment for the Orthodox Jew carries immense stigma and shame. Requiring the assistance of a mental health practitioner may be perceived as a personal weakness, and the fact that therapists are university educated can indirectly compound such feelings and contribute to being viewed as inferior, uneducated, or, in the

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words of Yaakov, “like he’s the doctor and I’m like an am haaretz [ignorant].” A therapy relationship characterized as too formal, rigid, authoritative, might be viewed and perceived as the therapist coming off as better than, judging, belittling, shaming, and so forth, and can make all the difference between a patient who commits to treatment versus one who is defensive, resistant, or who terminates prematurely. An egalitarian dynamic is thus all the more central when it comes to the Orthodox Jewish patient.

From a self psychological perspective, a therapy in which the patient benefits from a balanced and respectful dynamic, or, as participant accounts indicate, to be seen as a respected equal and included in the relationship with them, is most often associated with the need for twinship in which the patient can be valued, appreciated, fully seen. Or, as Miller (1996) writes: This other person is just like me, and that if they are like me, they can understand me. They will be perfectly empathic. I won’t be alone in my painful frustrations, or in my grandiosity, because I have someone to share it with. Even more, I will be able to learn to develop my talents or skills through interacting with this person (p. 38).

When this need is met, it produces the feeling that one is a human being among other human beings.

I’ve never, not once, got the feeling or impression that he looks at me differently or looks down on me. Why is it helpful? It preserves my sense of dignity I guess doesn’t make me feel embarrassed, like I don’t have enough of that anyways. It’s

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nice to feel like a human, you get what I’m saying? I think if he can accept me or treat me as equal, then I can be accepting of me and all the parts of me as well.

Something like that. (Yitzchak)

Summary.

Although anxiety with any patient may issue from the specific content of the therapy session, oftentimes, as illustrated by the participants of this study, it is more related to the process – from feelings about the therapist-patient relationship. And as participant accounts of this study demonstrate, the Orthodox Jewish patient places great importance on the authentic human encounter in psychotherapy (Yalom, 2002), characterized by the experience of feeling equal, valued and respected as a unique individual. All participants reported how being viewed by their therapist as human, like a real person, valuable, and not simply as patients, problems, or diagnoses was a helpful therapeutic factor. The experience of feeling valued as a peer-companion, satisfies the patient’s need for twinship and allows the therapist to become an idealized twin (Fosshage, 1997). And most interestingly, such a dynamic was not perceived to compromise the therapist’s professional qualities in the patient’s eyes.

This finding has implications not only for psychoanalytic/dynamic practitioners who might adhere to the blank-screen model, but even those utilizing a CBT approach, where the dynamic might be depicted as teacher-student. It is imperative to be mindful

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how such stances might impact the treatment with Orthodox Jewish patients, and to bear in mind the possibility of needing to adapt a more culturally accepted stance for therapy to be successful.

Going the extra distance.

All four participants spoke about the importance behind the smaller intimacies and extra-therapeutic courtesies, which were viewed as beneficial to their treatment.

Whether it was the remembrance of a child’s birthday, such as in the case of Sara, “I was shocked when, we were discussing my family and children, she asked if I could bring in photos of my kids and what their birthdays were! And she remembered them!”

Participants expressed how such efforts conveyed their therapist’s care, concern and genuineness. Other extra-therapeutic acts interviewees mentioned included, offering a session on the therapist’s day off, “I know my therapist doesn’t see clients on Sundays, but I really needed her, just to hear her voice at least. The second she heard my voice on the phone and what happened, without a second, she told me to come to see her and that she would be at her office for me in 30 minutes!” (Rivka), the therapist attending a patient’s milestone event, “And then one time I was making a siyum [celebration] on a masechta [volume of the Talmud] and I invited him to the siyum. Now, I’m aware of his rules, he’s told them to me in the beginning of therapy, and I thought this would be a pareve [grey] area, and that he would say no off the bat… Surprisingly, he asked me about the location, day/time, and said he would be honored to come for a bit and wish me

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mazal tov in person. And he did!” (Yitzchak), and a telephone call from their therapist even if the patient had not requested anything, such as in the case of Yaakov, “Also, sometimes he calls me in the middle of the week just to see how I’m doing… if, especially if I’ve had a difficult session… Because it’s things like this, that send a message that more than just a therapist, he’s an emesdica [genuine] person first, who cares about the people he sees,” (Yaakov).

In the research literature, extra-therapeutic acts, or borrowing Yitzchak’s term, “going the extra mile,” are defined as, “extensions beyond the confines of the consulting rooms” (Walker, 2002), and are termed boundary crossings in clinical jargon. In contrast to boundary ‘violations,’ which may significantly injure the patient and are usually not processed with care, boundary crossings may enhance the therapy, especially when they are examined routinely. Nevertheless, the research on the effects of boundary crossings are somewhat ambivalent. For example, Pope and Keith-Spiegel (2008) note, “nonsexual boundary crossings can enrich psychotherapy, serve the treatment plan, and strengthen the therapist-client working relationship. They can also undermine the therapy, disrupt the therapist-patient alliance, and cause harm to clients (p. 638).” While it is well known that Freud engaged in what would be considered boundary crossings, [e.g., offering a “victory” cigar to patients after an incisive interpretation, giving patients gifts, loaning books, sending Rat Man postcards and offering him a meal, and even providing financial support (Freud S. , 1909)], Gutheil and Gabbard (1993) object stating, “these behaviors are no longer acceptable practice regardless of their place in the history of our field” (p.

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189) and within the analytic tradition it is generally accepted that, maintaining clear and firm boundaries is highly important (Simon, 1991). Zetzel (1966) concurs that Freud’s serving Rat Man a meal was “unanalytic,” but nevertheless contends that: The Rat Man’s responses nevertheless illustrate a point which cannot be too strongly emphasized in our understanding of clinical psycho-analysis. A good analytic situation, although it may temporarily be distorted or modified, will not be undermined by occasional defections from traditional technique on the part of the analyst. (p. 127) In contrast, behavioral, cognitive, cognitive behavioral, family and group therapies support any boundary crossing, if they are likely to enhance therapeutic effectiveness (Lazarus & Zur, 2002; Zur, 2007).

In a discussion about patients’ views of helpful events in therapy, Yalom (2002) states that identified aspects are generally relational and often involve some act of the therapist that stretched outside the frame of therapy. Referring to this as “the therapeutic act, not the therapeutic word (p. 37),” Yalom stresses the importance of adapting therapy according to the individual patient or striving to create a ‘new therapy’ for each patient.

Such a task avoids manualized technique and encourages choices to flow spontaneously from the demands of the immediate clinical situation. Similarly, Lazarus (1994) emphasizes the need for flexibility and stresses the clinical significance of individual differences. He contends:

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With some patients, anything other than a formal clearly delimited doctor-patient relationship is inadvisable and is likely to prove counterproductive. With others, an open give-and-take, a sense of camaraderie, and a willingness to step outside the bounds of a sanctioned healer will enhance treatment outcomes. (p. 260) Stated otherwise, Lazarus believes it doesn’t hurt to temper rules and regulations with a touch of common sense.

McWilliams (2004) takes a more thoughtful approach stating the concept of therapeutic boundaries is far from simple. She acknowledges that patients and ex-patients tend to point to the moments when their therapist surprised them often by deviating from the frame as the most pivotal incidents in their treatments, but qualifies the idea of boundary crossings, by strongly stressing the security of the therapeutic dyad depends on observing a mutually understood consistent set of boundaries. It is precisely when the boundaries are clear to both parties, that, paradoxically, when the therapist steps out of the frame by responding to the patient with a spontaneous gesture or does something exceptional, that the most moving and healing moments in treatment occur. In other words, patients cannot be expected to appreciate the special meaning of a spontaneous moment unless it can be seen as an exceptional event. This idea is substantiated by participants in this study as well. Both Yitzchak and Yaakov describe how their therapists are generally disciplined, punctual, and set clear boundaries. It is quite possible, as McWilliams has stated, that the beneficial effect was viewed as such, only because it was

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exceptional and unexpected, that is, outside a therapy frame that is typically well established and consistently maintained and upheld.

From a self psychological vantage point, interventions which fall under the category of boundary crossings are seen as helpful because they have emerged from, and are in direct response to, understanding the patients experience. Such forms of experience-near interventions, in which therapists attempt to experience as closely as possible what the patient might be requiring, benefits the developing selfobject bond. In this way, boundary crossing interventions can be viewed as the spontaneous outgrowth of an empathically attuned stance, that enhances understanding and connection and is deemed helpful by the patient. This study comes to a similar conclusion. All participants emphasized how their therapy experience was fundamentally transformed after the therapist went beyond formality. Reports such as: “she gained my trust… She cares about me in a real way, and that shows me it’s not just business as usual for her,” (Sara), “I felt like I had someone there for me, I wasn’t alone, and uncared for… That’s not just a professional, that’s a real genuine human being!” (Rivka), “I am not just a parnassa for him. He really cares,” (Yitzchak), and, “it gives over a very important message to clients, at least to me that, that we matter and that the therapist is more than just a thing that exists when it’s a session” (Yaakov). From the patient’s perspective, going the extra distance was mutative in that it altered their impression of the therapist to a human being who understood their needs and genuinely wished to help.

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This is something very important to me. Says a lot about him, not just that he’s a professional therapist, or something like that, but it tells me about the type of mentsch he is. That he sees this type of work as more than just work. (Yaakov)

Summary.

All participants identified the therapist’s willingness to go beyond the boundaries of their formal roles as valued and beneficial. Participant narratives reflected an initial skepticism towards the therapist/therapy, and a therapist who made the extra effort was perceived as viewing treatment beyond the therapy hour, thereby enhancing the alliance.

While the research is clear that boundaries are a crucial element in patient-therapist interaction, good boundaries, however, are not necessarily equivalent to good therapy.

While some argue that actions or activities which take the therapeutic relationship outside the confines of the office should be avoided, many others believe that the decision should be based on the individual circumstances and relationship. This is especially relevant within the context of self psychology and the preeminence it places on empathy and the vicarious introspective mode of relating.

Boundaries between therapist and patient come in many forms and exist in various influential contexts (Gutheil & Gabbard, 1993; Zur, 2007). For clinicians treating the Orthodox Jewish patient, it bears keeping in mind that crossing them can have many potential effects. For the Orthodox Jewish therapist crossing boundaries might influence

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an already haimish [familiar] relationship and shift it to over-haimish [over-rapport], in which the therapist might relax his professionalism – becoming too unstructured or undirected, thereby compromising his ability to responsibly and optimally execute his therapeutic role. For practitioners trained in more psychoanalytic/dynamic schools of thought, by enforcing boundaries in a restrictive, defensive manner, such as the absolute non-acceptance of gifts, due to the cultural aspect of this population, it may interfere with the therapeutic alliance and with clinical effectiveness (Zur, 2017). In all cases a balance must be struck after a careful consideration and evaluation within the context it occurs.

The Therapeutic Factors The final superordinate theme of this study delineates the specific factors and interventions participants consider to be helpful about their therapy experience. At its core, the therapy process is infinitely complex, and there is no end to the number of pathways which make up a successful experience. Hence, no explanatory system can encompass all of therapy. Nevertheless, participant accounts remind us that we must listen to what our patients tell us and consider what they find helpful. At the same time, each factor alone is only part of the process and must be complemented by other factors, in order to provide a robust, successful psychotherapy treatment.

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This theme specifically answers the research question: “What are the specific beneficial elements of the therapeutic encounter as experienced by Orthodox Jewish patients?” and is broken down into five subthemes: 1. Self-Understanding 2. Psycho-Spiritual Integration 3. Psychoeducation 4. Highlighting Strengths 5. Climate of Hope

Self-understanding.

When discussing self-understanding or insight, several authors note that because it is not a unitary concept it tends to defy a precise definition and description. Instead, Yalom (2005) prefers to employ it in the general sense of “sighting inward,” which is said to have occurred when an individual discovers something important about oneself, whether about one’s behavior, one’s motivational system, or one’s unconscious. Along these lines, it bears mentioning that when summarizing the various views on insight, Thoma and Kachele (1987) remark that nearly all authors express the opinion that “true” insight or “seeing in” lies between the poles constituted by emotions and intellect.

Furthermore, Zilboorg (1952) recommends distinguishing between cognitive insight, which may act as a resistance to change, and emotional realization. He advises that therapists be alert to this difficult distinction between the defensive use of insight and its

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positive role in promoting progress and growth. In this study, all participants emphasized various forms of insight and credited it as being one of the beneficial factors of their therapy. Three of the four participants focused more on the cognitive dimension, which involved an identification and comprehension of dysfunctional patterns, while for one participant insight included an affective-behavioral dimension.

In her account, Sara describes how “needing a way to make sense of it all, like an explanation of sorts,” was helpful in that she acquired a new understanding and knowledge about her motivations, her behaviors, and her feelings. “Knowing that I have always needed people’s admiration, always saying yes, yes, yes, turned me into a shmatte [doormat], leaving me with feelings of resentment, anger and hurt.” In contrast to the three other participants, there was an additional component to Sara’s insight which proved beneficial, in that insight allowed for a new experience. ‘New’ in the sense of being different from and more functional (healthier) than her previous pattern she had been accustomed to, and ‘experience’ in that there was a heightened affective learning.

This is illustrated by her being able to refuse having her husband join her therapy sessions.

This knowledge allowed me to make more sense of a lot of things not just in therapy, but to situations in the outside world as well. Knowing how and sometimes why I operate a certain way has been very beneficial for me personally, baruch Hashem [thank God]. (Sara)

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This idea of behaving differently and emotionally appreciating behaving differently, highlights the affective-action component of insight mentioned above. As Frieda Fromm-Reichmann is credited with saying, “what the patient needs is an experience, not an explanation.”

Learning how her past has played a formative role in her present behaviors has been “instructive” for Rivka in that it has enhanced her self-understanding and awareness without exempting her from personal responsibility and accountability.

I have learnt that I react to some people or situations unrealistically with feelings that belong to earlier periods of my life and this has been extremely helpful for me. This type of understanding on the one hand gives me greater insight into how and why I sometimes may act like I do. It’s been helpful to know how I feel and behave today is related to my childhood and development, meaning there are reasons in my early life why I am the way I am, because it still doesn’t absolve me from responsibility and allows me to be more aware. (Rivka) Through an explanation of the impact of her early family and environmental experiences, Rivka understands the genesis of her current patterns of behavior. Yalom (Yalom & Leszcz, 2005) labels this type of insight, “genetic insight,” in that it helps patients understand how they got to be the way they are.

For Yitzchak, self-knowledge allowed for the integration and rediscovery of all the various parts of his self, particularly the positive parts, which in turn provides him with a sense of effectance and mastery.

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I hated myself, I couldn’t stand most parts of who I was. Through therapy session after session, my therapist again and again, allowed me to talk freely without judgement, I was able to somehow rediscover the positive parts of who I am and the person I am. It’s an amazing thing and feeling. Yes, I am still confused about my feelings for men, but I’ve come to accept this – it’s maybe just who I am and doesn’t have to negate all the other parts that make me Yitzchak. And there are many good parts of me. (Yitzchak) Thus, in Yitzchak’s case self-understanding included the recognition, integration, and free expression of previously dissociated parts of himself. Insight allowed him to reclaim those split-off parts thereby decreasing ambiguity and allowing him to come to terms with troubling, puzzling, inner alien impulses demanding expression.

You know, like a puzzle, before it’s put together, its 1000 pieces all over the place, and that was me when I started therapy. But worse, because I wanted and maybe I did, I threw away some of those pieces, I didn’t want them. I don’t think the puzzle is complete but it’s getting there and at least I can deal with all the pieces! I am okay with all the pieces. It’s like I found a new me, but that ‘me’ was there all along. (Yitzchak) Insight for Yaakov included the discovery of similar relational patterns with different people in his life thereby enabling him to examine his role in perpetuating dysfunctional interactions with others.

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That’s the really helpful part for me, it’s not that I ever thought I was meshuga [crazy] or something, but I definitely struggled with trying to figure out why I was constantly finding myself in similar types of situations with some people. And it created a real pachad [fear] the not knowing I mean. So yes, if I’d have to say what was helpful, in my opinion this part of therapy was… Especially if it’s about yourself and how you’ve been. (Yaakov) As mentioned earlier in the literature review section of this paper, from the outset of the psychoanalytic movement differences existed between theorists who attributed changes in the patient more to systematic interpretation of drive and conflict and those who attributed them more to the experience of a particular kind of relationship. As relational ideas became more rooted within the psychoanalytic community, there was an increasing attention to insight as an outcome of psychotherapy. Members from the relational camp questioned whether the analyst’s understanding is necessarily superior to the patient’s, and therefore de-emphasized the therapist’s responsibility to “convey” insight via interpretation. Consequently, from the relational perspective, insight is viewed as a natural product of the therapeutic collaboration, one that emerges organically in both the patient and therapist, once a sufficiently authentic and reliable relationship is secured between them. In other words, instead of being seen as the cause of intrapsychic change, insight is seen as one of its consequences, as evidence that change has happened. Self psychologists (following Messer and McWilliams (2007) who include Kohut as part of the relational camp), credit the advent of insight to the reduction of shame; others connect

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the emergence of insight with the natural human curiosity and creativity that become manifest within a context of the emotional honesty of both therapist and patient (Orange, 1995).

And what of the literature on this topic? The psychoanalytic research literature investigating the therapy process offers robust support to the relational perspective (Messer & McWilliams, 2007). Empirical data suggests that increased insight is, as relational analysts and others have posited, an outcome of successful psychoanalytic therapy. For example, members of the San Francisco Psychotherapy Research Group, who have conducted research on psychoanalytic therapies (Weiss, Sampson, & The Mt. Zion Psychotherapy Research Group, 1986), concluded that patients come to treatment with an unconscious idea or “plan” about the kind of experience they need in order to unlearn maladaptive childhood beliefs. Such beliefs exist outside their conscious awareness and are seen as responsible for their psychological suffering. Patients unconsciously devise tests that the therapist must pass in order to reduce their anxiety that the experiences that created the pathogenic beliefs and associated painful emotions will be repeated. If the therapist is successful in understanding the plan and passes the tests, the patient experiences a “condition of safety” in which psychopathology diminishes.

Along with such changes, previously warded-off contents of the mind emerge. Thus, insight arises as an outcome of therapy, of learning that the world is not necessarily dangerous in the ways the patient has previously assumed (Bateman & Holmes, 1995).

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This was and still is one of the most best parts of my therapy and how it has been helpful for me. I can’t explain how this happened or whether my therapist did something specific, I don’t think so. And it’s not something I realized right away, you know, like there was this moment. But it was over time, like one day, I just looked at myself and how far I have come. My therapist calls it “the process.”

And it’s like I feel whole again, I can’t explain this any other way, it’s just a feeling that’s really hard to put into words. You know, like a puzzle, before it’s put together, its 1000 pieces all over the place, and that was me when I started therapy. But worse, because I wanted and maybe I did, I threw away some of those pieces, I didn’t want them. I don’t think the puzzle is complete but it’s getting there and at least I can deal with all the pieces! I am okay with all the pieces. It’s like I found a new me, but that ‘me’ was there all along. (Yitzchak)

Summary.

In summary, while the gradual acquisition of insight is an intrinsic part of treatment, there is no agreement as to its exact meaning. Participant accounts indicated the helpful aspect of insight took form in several ways: gaining a more objective perspective on their interpersonal presentation, learning how they are seen by another person, learning why they do what they do to with other people, linking past and present, and bringing about greater harmony between conflictual wishes, enabling the individual to modify and tolerate previous ways of functioning.

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From a self psychological perspective, insight is not ‘given’ by the therapist, rather it is assimilated by the patient, bit by bit. Specifically, when the patient feels safe relating to the therapist in ways that differ from past behavior with important people, insight follows. In this way, insight is an outcome that does not have to be explicitly pursued and for which the groundwork does not have to be self-consciously laid. And while the debate about the main task of the therapist will no doubt continue to rage on, participants from this study corroborate the words of Proverbs (11:22) that, “understanding is the well-spring of life” and insight certainly plays an important role in their therapeutic process and treatment.

Psycho-spiritual integration.

When it comes to the constructive aspects of religion and spirituality in the treatment setting, Marcus and Rosenberg (1995) note that this experience has generally been underappreciated by the psychoanalytic community and literature. They posit that this attitude follows Freud (1927), who highlighted the psychopathological meaning of religious cognition and behavior. Conversely, when discussing various approaches adapted in conceptualizing religious experience in clinical settings, Goldberg (1996) uses the term the ‘functional perspective’ which describes “the selfobject functions served by the matrix of religious meaning within which the patient lives.” She feels therapists may be reluctant in adapting a functional approach, given their own religious beliefs, or lack of, or because they believe religious experiences are in a special category of meaning that

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is not within the realm of clinical inquiry. To be sure, this is unfortunate, given that participants from this study all verbalized how a therapist/therapy integrating religiocultural and clinical expertise was vital to their growth in treatment. In fact, this might be the one beneficial factor more so than any other factor which specifically applies to the Orthodox Jewish patient vis-à-vis the secular one. Indeed, Starck’s study (2008) came to a similar conclusion, in that having a therapist who offered both religio-cultural and clinical expertise was identified as most beneficial for Orthodox participants. Her participants reported that being able to locate, explore and examine the spiritual dimension filled an existential gap which they felt was germane to their internal conflict.

All research participants in this study identified how the ability to freely discuss Hashem [God] and other Jewish-related material, without fear of being shamed, judged, or invalidated, as well as having a religious-syntonic response, played a real and ongoing role in each participants decision to seek and remain in treatment.

Sara shared that having a therapy and therapist that in some way offered her the ability to express content in a manner that she would with any of her friends made her “comfortable.”

Being able to talk about Hashem [God] is something which has been helpful for me in my therapy. What is my role as a mother and what does Hashem expect of me and working through and talking about my relationship with Him and the feelings which come along with this makes me feel at home with my therapist… I

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want and need my conversations with my therapist to be no different than with my friends and I expected to be able to talk about this comfortably. (Sara) She qualifies this by stating that therapy and its dialogue should offer a qualitatively different experience, something more than simply “chatting,” perhaps something deeper and of more substance. “That has been one of the benefits of working with a frum [religious] therapist, she’s able to listen and understand and our discussions don’t come off as a bunch of frummie [religious] women chatting about Hashem [God].”

(Sara) Rivka concurs and believes that having a treatment in which there was an acknowledgment about the importance of, and connection to, Jewish ideology and philosophy was not only helpful and necessary but was crucial to the deepening of her therapy experience.

For my therapy it was and continues to be a very important and I’ve come to find necessary part of good treatment for me. I think it was something which I was so badly needing to have a discussion about, and it really deepened my therapy by us being able to talk about these things. I’d imagine any frum yid, man and woman would be needing this to be a part of their treatment. (Rivka) Yitzchak was the most verbal in articulating his belief that his symptoms might stem from a spiritual source and “emptiness of the soul,” and that having a therapist who in addition to being trained professionally was also sensitive to such ideas was beneficial

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to his treatment. “And I’ll be the first to admit it, I feel sometimes so empty, like my neshamah [soul] ran out of gas or something like that, and it gets me depressed and anxious. I’m a yeshiva guy you know, and what I like about my therapy is being able to talk about this, but not getting the “mashgiach response” which is typical, and most guys will tell you is just being told to learn and daven [pray] more.” This included his therapist collaborating with his Rov/Rabbi and being able to frame his relationship with God in professional terms. Such integration allows Yitzchak to fully appreciate and develop in his religious convictions. “I feel like I’ve grown more genuine and real in my appreciation with Yiddishkeit and hashkofa through this than learning in yeshiva.”

(Yitzchak) Yaakov finds that having a treatment in which the Torah source or root behind the psychological content can be discussed, having a “balanced package” therapist is crucial for effective treatment and he questions whether it can be any other way. He values the ongoing possibility of introducing this in his therapy discussions at any given moment and cannot imagine a therapy without it.

I realized, quickly, so much of psychology has its shoresh [roots] in the Torah, and I think for me a helpful and important part of it is that the therapist be familiar with both. It makes the treatment much more meaningful when there is a Torah source to what he is saying or explaining. I mean, at this point, I really can’t understand how you cannot have it, I mean I need to be able to talk about haskofah [outlook] and tafkid [purpose in life] in addition to figuring out my

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relationship with Hakodosh baruch Hu [God] and how emunah and bitachon play a role in my life… A balanced package is what I think is one of the most important parts of therapy for people in our community, for sure the yeshivish crowd. (Yaakov) This leads us to wonder why a “balanced package,” borrowing Yaakov’s term, or treatment which integrates the psychological and spiritual is so important for the Orthodox Jewish patient and how might this be understood from a self psychological perspective?

To start, the research indicates that mental health may be promoted through spiritual means (Bergin, 1991; Miller & Martin, 1988; Richards & Potts, 1995; Shafranske & Malony, 1996), with some studies suggesting that certain patients may be effectively treated only when therapists respond to their spiritual and religious issues (Bergin, 1991; Kelly, 1995; Shafranske & Malony, 1996; Worthington Jr., Kurusu, McCullough, & Sanders, 1996). For example, Shafranske (Shafranske & Malony, 1996) outlines four reasons why religious issues should be included within the clinical work.

This inclusion is justified in light of four interrelated factors: the professional ideal of cultural inclusion; the substantial evidence of religion as a cultural fact; the developing body of theoretical, clinical, and empirical research literature concerning religion as a variable in mental health; and the appreciation of psychological treatment as a value-based form of intervention (p. 56).

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From the self psychological side of things, Holliman (2002) posits that religious experience can serve as a resource for satisfying selfobject needs and cites Jones to demonstrate the implications of a self psychological approach to patient religious experience.

Congruent with this model of understanding [Kohut], religion would be defined not primarily as a defense against instincts or a manifestation of internalized objects but rather as a relationship (with God, the sacred, the cosmos, or some reality beyond the phenomenal world of space and time). And the psychoanalytic study of religion would investigate the way in which individuals’ religious beliefs, experiences and practices reflect the dynamics active in their construing of experience and in the deep structure of their internalized relationships (Jones, 1991, p. 63).

She goes on and differentiates four functions that religious expression may fulfill for the individual. Two of them are relevant to the subject matter: (1) provide compensatory structure; and (2) enhance development of self structure. Holliman (2002) posits the more rigid the religious belief or practice, the greater the possibility that the person’s religious experience is compensatory and serves to protect a core sense of self.

From a self psychological view, religion may serve as a unique resource in defining and supporting a functioning self, but, similar to Freud’s single understanding of the function of religion, it does so by defending against conflictual material that is denied and repressed.

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Consequently, a well-integrated treatment, is one which delicately balances how questioning the Orthodox Jewish patients’ religious structure by attempting to impose other ways of thinking about God or by attempting to impose psychological meaning through emotional language can result in heightened resistance, if not flight, with an understanding how resisting this challenge serves to protect the weak, unstable selfcohesion. An integrated treatment is necessary and helpful for the Orthodox Jew, because rather than challenge there is a sensitivity, in which the therapist works with the religious ideation and allows the religious experience to function more adequately as compensatory self-structure resulting in a more stable and solid self-structure. Rather, the guiding question as raised by McDargh (1993) quoted in Holliman (2002) should be: How is this God part of a total schema of faith or comprehensive meaning-making that [the patient] somehow needs in order to be a self? (p. 200) The other function that Holliman presents is, religion not only contributes to the sustenance of self-cohesion but can actually enhance the development of the self.

Holliman feels this is particularly true of persons who have grown up in nurturing religious surroundings that provide age-appropriate educational, worship, and social programs designed for developing children and adolescents. This of course would include the Orthodox Jew, whom, as explained at length in Chapter II, comes from a very insular and close-knit community which welcome, nurture, value and affirm through participation in various activities. Further, for the Orthodox Jew who might struggle to understand themselves and their religious culture vis-à-vis the surrounding “secular”

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culture, being part of a larger community in which one is like many others allows him to thrive and feel connected to others who could understand his experience in meaningful and similar ways. A balanced package therapy/therapist allows for self-cohesion and viewed as helpful because it is more strongly aligned with the ideals as represented by the religious community and can satisfy the need to be among similar others.

In light of the above, we return to the question and are left to wonder whether the Orthodox Jewish patient would be better served with a therapist who is ‘cut from the same cloth’ or more culturally aligned with Orthodox Judaism. From participant accounts in this study, it would appear that the answer is yes. All participants were in agreement that working with a frum therapist was not only helpful but was necessary and required.

Sara feels a secular therapist cannot truly be effective due to the lack of true appreciation to the religions nuances and value system.

Well, I need to feel comfortable talking about issues and practices relating to Yiddishkeit [Judaism]. As a Jewish woman, specifically the mitzvah of Taharas Hamishpachah [Laws of Family Purity] other topics that pertain to women and family life, I need a therapist familiar with these halachos [Jewish guidelines/laws]. Also, my husband sits and learns, it is extremely important to me that I could talk openly about this with someone who gets it, you know, and appreciates the value and great z’chus [merit] this is. I’ve had two friends who went to therapists out of the community and the feeling they got when talking about their husband’s preference to spend many hours sitting and learning Torah

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for a living, was the therapist’s reaction of disregard for this value. That would be absolutely terrible if I had to go to therapy and couldn’t discuss certain topics that play a major role in my daily living and beliefs, couldn’t discuss it comfortably and without feeling misunderstood or judged or laughed at. That’s why I would only go and why I chose to go to a frum therapist, I don’t think, I wouldn’t recommend for anyone in my circles to go to a non-frum or goyisha [non-Jewish] therapist. Not because I don’t think they’re good or professional or anything like that, but how can they get our lifestyle, our hashkofa [philosophy], the halachos and all the things that makes us frum Yidden [religious Jews]? It’s just my opinion but I feel very strongly about it. (Sara) Rivka is doubtful whether she could connect with a non-religious or non-Jewish therapist and worries lest the ideas or discussions be in opposition to Torah values and ideology. She states: I am not sure if a non-Jewish or even a non-frum therapist can provide this because I know for myself I could not fully connect or accept the ideas such a person would put forth, in the same way my therapist, a frum woman does. I guess I’d always be doubtful if it represents kefira or if it is line with frum, Torah hashkafa. (Rivka) Although initially Yitzchak had his doubts about whether he’d feel comfortable being open with a Orthodox therapist, choosing to stay with his Orthodox therapist allows him to feel connected to his Judaism, values and community.

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I seriously considered going out of the community for therapy. For many reasons, which I’m sure you khop [grasp], this being one of them. But I think because he’s really good, and we had a relationship before, when I was seeing him when I was married, and I remember thinking how much I’d be giving up if I go somewhere else out of the community. This way, I mean sitting each week with a frum guy, good hashkafos [ideals], uh, you know yarmulke [skull cap], ben Torah [learned Jew], able to juggle both his professional and Yiddishkeit – you know that’s really what I’m needing! I’m really happy I decided to stay with him and stick with it.

I’m trying to juggle too, would have been a big mistake to leave him, I think it really would’ve been the first step of going off the derech [path] for me, baruch Hashem [thank God] there was hashkochah pra’tis [personal Divine intervention] and Hashem was looking out for me, and allowed me to finally make a good decision (smiling laughing lightly). (Yitzchak) For his part, Yaakov states: Look, I think it’s impossible for it to be separate, you can’t not include it in therapy and there’s no way I would ever have considered looking for therapy or a therapist who couldn’t talk knowledgably in areas of halachah [Jewish law] and haskofah [philosophy], especially since so many of the issues are tied to this.

Even though I don’t think I realized it at the time, you know at the start of my therapy. Even sholom bayis and tahras hamispachah [family purity], these are such main parts of our lives, and not understanding this and being able to talk

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about it in therapy is a shud [shame]! In my therapy I talked about so many of these areas, olam haba, bechira, sholom bayis, yetzer hara, and while I don’t agree, I’m not always maskim [in agreement] with everything he puts forth, at least I feel comfortable that we can at any time include this in my therapy. I would not be able to imagine it being any other way, le’chorah [ostensibly].

(Yaakov) These findings contrast with Starck’s (2008), who concluded that while her participants all appreciated their therapist’s ability to value their worldview on the interrelated issues of gender-role, spiritual expression, career and family, they were not however, particular about the therapist’s religious identity nor was it initially specifically considered by the patient-to-be. As long as the therapist knew enough about normative Orthodox behaviors and lifestyle, therapist religious identity was not a factor for Starck’s participants and educating their therapist about the unknown aspects of Orthodox Judaism sufficed.

Participant accounts from this study are clear about being unable to fathom working with a non-Jewish or secular therapist. What might account for these disparate conclusions? One possible notion was mentioned above in the literature review section.

There are varying degrees and nuances within the category of “Orthodox Jewish” and where one identifies and locates themselves on this spectrum has real life implications as it pertains to Jewish ideology and practice. Whereas Starck’s participants appear to selfidentify as being somewhere between Modern Orthodox and Yeshivish, participants from

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this study identify as more “Black Hat Yeshivish,” which is typically associated as more extreme or religious than its counterparts from the Modern-Orthodox, or middle of the road camp. Consequently, what is acceptable for, and the level of sensitivity of, those identifying within one Orthodox Jewish subgroup might not be for those within a different group, as in the case of these participants. Indeed, Wikler (1983) found that more stringently Orthodox clients were more likely to choose Orthodox therapists, while the modern Orthodox were more open to seeing a secular therapist. His finding lends further support to the contention that the Modern Orthodox are more receptive to utilization of secular therapists due to their greater openness to secular culture, while the stringently Orthodox keep a distance from secular culture in part because they see its values as potentially threatening and unsafe which is why they feel insecure with a secular therapist.

Additional research addresses the question of whether it is important for the Orthodox patient and their therapist to be religio-culturally matched might be of frequent concern to Orthodox patients and for the most part is inconclusive. For example, Friedman and Lob (2003) reported that there “are highly respected rabbis on both sides of the question as well as many rabbis who decide this issue on a case-by-case basis” (2003, p. 35) Friedman believes that Orthodox Jews have reason to be concerned about therapist bias in religious matters in light of psychoanalysis’s history of being dismissive, if not hostile, to religious belief and practice. Yet, she acknowledges that in more recent times the field has evidenced a growing regard for the place of spirituality in providing support,

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as well as an appreciation of the limitations of psychology in addressing existential questions. Though many Orthodox Jewish patients might favor being treated by Orthodox Jewish therapists because of its inherent advantages, this arrangement holds not only reciprocal potential disadvantages for the patients, but for the treating therapist as well.

Wikler (1990) discusses the occupational hazards of conducting “fishbowl therapy,� that is, of Orthodox therapists treating Orthodox patients with whom they are likely to have overlapping social networks, which may then involuntarily place the therapist into a personally exposed position, and a professionally vulnerable one as well. Because of this, Wikler advises Orthodox therapists to reduce their vulnerability to such hazards through increased mutual support in the form of membership in Orthodox professional associations and peer groups, and through participation in conferences for Orthodox clinicians.

In sum, it would be safe to say that from research participants accounts, regardless of the therapist’s religious identity, therapy with the Orthodox Jew, is perceived as beneficial if it can integrate the religious and psychological and thus serve as an expression and extension of their religious experience. An integrated treatment or therapist of this kind, can then evaluate the use a patient is making of religious experience through empathic inquiry into the meaning of the religious experience for the patient.

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Summary.

The Orthodox Jewish patient values a therapeutic approach that incorporates the psychological and spiritual. That means, when it comes to the Orthodox Jewish patient, practitioners from all perspectives, including self psychology, have to pay more attention to understanding the religious experiences of their patients. Self psychology has the potential to greatly enhance theory development and clinical practice in the use of religious experience. Consequently, the implications of a self psychological approach to religious experience in general would be a functional perspective which avoids the evolutionary origins of religion and rather, conceives of religion as a form of selfobject experience that can meet selfobject needs and help sustain the self.

Because the Orthodox Jewish patient might prioritize religious matching/familiarity and clinical competency, when working with this population the following considerations might prove helpful: 1. Familiarity with aspects of Orthodox Jewish lifestyle and philosophy.

2. Encouraging Orthodox Jewish patients to educate the therapist about aspects of Judaism, or of their Orthodox practice and lifestyle. And lastly, 3. Have an expert in Orthodox practice with whom to consult.

One final point before concluding this section. While it is true that Orthodox Jewish patients, such as the four participants in this study, might seek an Orthodox Jewish therapist or therapy because of the perceived cultural similarity and background, at the same time it bears keeping in mind that they might do so with conflict. On the one

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hand they may believe that such a therapist will understand their spiritual journey – and might even share their experience – which facilitates trust. On the other hand, they may expect or fear the therapist to take the side of the religious community. In the words of Brickman (2002): Religion may in some cases satisfy needs; in other cases, however, it may purposefully frustrate those needs, bringing unrest, disquiet, and even anguish in the search for religious truth. (p. 213) In all cases then, it is the job of the therapist to accept any such experiences and tolerate the consequential distrust. And while psycho-spiritual integration is important, as a standalone it is not sufficient to provide a beneficial treatment for patients. Patients seek specific assistance in their therapy with therapists. For some, obtaining assistance with tools, skills, or education is important, which leads us to the next identified beneficial factor, psychoeducation.

Psychoeducation.

The importance psychoeducation plays in the treatment of the psychotherapy patient should not be surprising. To wit, the idea that psychotherapy, as an enterprise, would be conceived of as education, is not new (Gedo, 1979; Szasz, 1974). Indeed, Marsh (1935), writing in the 1930s, also believed in the importance of psychoeducation and organized classes for his patients, complete with lectures, homework, and grades.

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When writing about psychoanalysis in the context of being a therapy, Freud was noted to (1905; 1916; 1926; 1938) refer to psychoanalysis as a type re-education, that is, a learning which postdates and corrects infantile inferences. In a discussion on this point, McWilliams (2003) states: Most of us would probably agree with Freud that psychotherapy is not so much a medical procedure as a particular kind of education: an intense, deeply personal, emotionally powerful, intimate kind of education. (p. 247) Nevertheless, as Busch and Auchincloss (2018) note, discussing psychoeducational interventions within the context of psychotherapy has generally been avoided by psychodynamic therapists. The authors contend that psychotherapy utilizing education has typically been denied and devalued both by classical analysts who would cite threats to analytic neutrality, as well as relational analysts who would argue that education places the analyst in a position of unwarranted authority.

That being said, participant accounts indicate the value of psychoeducational approaches for engaging patients in psychodynamic psychotherapy. Anecdotally, it is interesting to note, that in a candid discussion about her own experience as a psychotherapy patient, McWilliams talks about how her deeply transformative analysis contained moments when she felt that the information she picked up in the process was more healing than the work she and her analyst were doing on transferences and resistances. She states:

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These moments fascinated me at the time and left me with an enduring interest in the therapeutic benefits of information that comes through a relationship of unparalleled emotional power. (2003, p. 248) McWilliams then shares findings about her own psychotherapy patients and notes how patients whose treatments had gone well tended to attribute their progress not to her interpretations of resistance but “to passing comments or unselfconscious actions of mine that stimulated new ways of understanding their lives and life in general. In other words, they put more emphasis on having learned things that felt new rather than on having come to realize things they had known unconsciously (p. 248).” She concludes that whether or not they see what they do as education, therapists from all theoretical backgrounds, explicitly or implicitly educate their patients. Explicit educative activities include teaching patients how to collaborate in the therapeutic process, while implicit interventions, that is, without necessarily being didactic, include information to patients about many aspects of life, including emotion, development, trauma and stress, intimacy and sexuality, and self-esteem. Research participant accounts from this study contain various aspects of psychoeducation which were deemed helpful, including education about the patient’s problems, how the treatment works, and information about relationships and communication from areas of psychology.

Beginning therapy from a place of unknown is extremely anxiety provoking for Sara, whose imagination conjured up a catastrophizing and self-defeating responses for her struggle. Being told by her son’s therapist that she would benefit from her own

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therapy but not understanding why, had her thinking she was crazy and needing medication. “For me, I created a whole anxiety imaginative explanation for needing to go, especially since my son’s therapist recommended it as well. Like, what’s it supposed to mean if a professional is telling you to go for therapy? Like, maybe I had some personality issues or mental illness and would need medication which is my biggest fear.”

Sara’s narrative illustrates how in psychotherapy, patients can be reassured by the belief that their frenzied inner world, their suffering, and their complex interpersonal relationships are all explicable and thereby governable. Increasing her knowledge about her symptoms and doubts, had transformative effects and provided her with a sense of safety, anxiety reduction, and mastery. She states, “It was like a weight was taken off my shoulders… being given information about these things – even if it’s not such great information, like who wants to be told that they have anxiety or things like that, but still it’s comforting. At least I know what I am working or dealing with and I can deal with that.” (Sara) Along these lines, Maslow (1963) viewed psychiatric illness as a disease caused by “knowledge deficiency.” In this way, he would seem to be in agreement that psychoeducation about a patient’s problems is beneficial, helpful and cathartic.

Rivka highlights another aspect of psychoeducation, namely, being informed about specific therapy processes and ways of being. “Like, she usually won’t just answer a question I ask of her, and it was really bugging me, I guess she picked this up and we discussed this – also, why this was so annoying for me. I felt much better after these type of discussions.” For Rivka, it is important and helpful to have a basic understanding on

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how treatment works. This includes being educated about the context of her therapists’ inquiries and provided with explanations regarding the various techniques and ways of being therapists tend to operate from. McWilliams (2003) refers to this as teaching patients “how to be patients” and reports that such types of educative interventions are therapeutic and furthers the treatment.

The empirical literature has weighed in strongly on the value of helping a patient understand how to be a patient. Over 50 years ago, Orne and Wender (1968) published findings on what they called “anticipatory socialization.” Among other things, they found that preparing the patient for negative feelings toward the therapist facilitated treatment significantly. And while traditionally negative transference is addressed as early in treatment as possible, the stress on how the patient is prepared for looking at this is seldom mentioned in analytic writing on technique. With first time psychotherapy patients in general and the Orthodox Jewish patient in particular who might be suspicious about treatment, McWilliams asserts that it would be a mistake to assume that patients know the rationale underlying therapist questioning and interpretations. She suggests that at times, it would be helpful for therapists to share with their patients the reasoning behind such interventions. In the case of Rivka, being informed allowed her to feel recognized as a functioning and intelligent human being.

Like I’m a smart respectable person, and not simply a patient who is sick and being analyzed by some person who gives off this impression of having some great knowledge about me that no one else, even myself, know about me! I think

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anyone would appreciate feeling like their therapist respects them as an intelligent capable human being – it just makes sense to me. (Rivka) Yitzchak and Yaakov both feel that learning about relationships, styles of communication, from an expert perspective, was deemed necessary and helpful. For Yitzchak this provides him with a sense of something concrete, something “le’maisah” [practical], which gives him a sense of direction and grounding.

I need to know clearly how to do things differently and an explanation of the psychological reason for things, I really like that, it helps me to understand things better and practically I could use them moving forward… I like that a lot, its practical and after those type of sessions I feel like I’m taking something away practically, and have something to work with and towards, a real goal, you know what I mean? Not some pie in the sky thing. (Yitzchak) Yaakov views therapy as necessary so long as “there’s more I can learn.” The occasional psychoeducational intervention reinforces his decision to seek and remain in therapy by reminding him that there are aspects to his experience which can benefit from a professional objective perspective and outlook.

In a way, I think that’s what keeps me coming back and paying, because b’emes [truthfully], it is expensive, but knowing that there’s more I can learn, and I think more importantly that my therapist has knowledge about things which can be helpful for me whether it’s better understanding myself or my children is what keeps me there. Otherwise, to be honest, I really don’t think I would be in therapy

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this long. And probably, once I get to the point where it becomes stale, I’ll end.

(Yaakov) McWilliams corroborates this as well. Therapists are in the position of being able to claim privileged knowledge about areas which are of central concern to people, specifically as it relates to life, human nature and change. She opines that the primary value bestowed by the psychoanalytic tradition is its knowledge base not the mastery of theory, thus, conveying such knowledge to patients and the subsequent learning can be therapeutic. In her own words: It is my own orientation to the psychoanalytic tradition to see its value as lying not in its mastery of a particular type of psychotherapy but in its knowledge base.

The impetus that created psychoanalysis, the disciplined effort to understand and help difficult and suffering people, has generated a body of knowledge that suffuses our understanding of life and human nature and change. This knowledge gets transmitted both actively and passively to our patients, and I want to emphasize its therapeutic potential. (2003, p. 249)

Summary.

Participant accounts highlighted how various aspects of psychoeducation, were deemed beneficial. Contemporary psychotherapy research has increasingly included psychoeducational interventions and its benefits in its clinical descriptions. As

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McWilliams has cogently argued, regardless of whether or not we adapt a teaching mode, most patients at the conclusion of successful therapy, have learned through an implicit educational process, a great deal about psychic functioning, the meaning of symptoms, interpersonal dynamics, and the process of psychotherapy. So that, whether therapists choose to acknowledge it or not, education is intrinsically tied into treatment.

While the literature on the benefits of including an educative component is certainly not limited to the Orthodox Jewish patient, there are several considerations which speak to the unique cultural make up of this population of which practitioner’s need be attentive. Firstly, it would not be an exaggeration to assume that upon entering therapy for the first time, the Orthodox Jewish patient might encounter a culture shock resulting in much angst, misconception, ignorance, or skepticism associated with the therapist and therapy process. Practitioners can ease this transition by offering instruction about the nature of the therapeutic experience and how to be patients. Those practicing from an analytical or dynamic stance can include discussions about the rationale behind reporting free associations, dreams, the use of the couch, and about the fact that the therapeutic relationship itself will be scrutinized. Secondly, Orthodox Jewish patients who have never engaged in any form of psychotherapy may come with several cultural preconceptions. The closest experience to therapy they may have had would be with their Rabbi, a dynamic typically characterized as providing a teshuva [response] to a posed shaila [question]. This type of interchange differs markedly from the self-exploration often encouraged in therapy and may disappoint or confuse a patient who has different

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expectations (Greenberg, 1991). Educating and imparting information regarding psychotherapeutic aims and processes would prevent such unnecessary frustration and confusion.

Lastly, as explained at several points throughout this paper, the Orthodox Jewish patient might be more prone and sensitive to feelings of shame than the typical psychotherapy patient. Consequently, the Orthodox Jewish patient might require some evidence of the therapists’ assumption in the context of a clarification or interpretation when disclosing something subjectively shameful, which would otherwise fall within the territory of being human. It becomes all the more critical therefore, for the therapist to be proactive in framing this within a context and tone of normalization.

Highlighting strengths.

All four participants highly valued a therapist and treatment in which their strengths were promoted and emphasized and where weaknesses and deficits weren’t the exclusive focus.

Although Sara felt challenged by some of the dynamics in the relationship with her child, she appreciated the fact that this was never turned into a reason to develop a negative attitude about herself. Rather, her therapist worked to promote a healthful parenting outlook by highlighting Sara’s abilities, successes and strengths within the parent-child relationship. She states:

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So, it’s really helpful when she’s able to point out my strengths when my tendency is to concentrate on adversity which causes me to doubt myself and doubt how I feel about myself. And at such times she is able to point out the strengths and the abilities that I have. It is really helpful for me and building my self-esteem back up. (Sara) Rivka appreciates a wholesome therapeutic perspective that includes exploration of positive events, good times, strengths and abilities, thereby preventing her from getting caught up in a negative tunnel vision view of life as an unmarried older single. She states, Looking for what is right and how to help use it… My therapist is constantly looking, refocusing me, pointing out at what has gone well for me and not allowing me to have such a narrow focus or discussion… Our discussions have constantly focused on the things in my life I am proud of, my previous and ongoing achievements, and other areas I tend not to focus on or think about otherwise. Look, as an older single it’s very easy for me to fall into self-pity, anger, bitterness, and see everything through that perspective, and by her pointing out what is going right in my life and how to not only build on it but to use that in other areas, is really beneficial for me and gets me through those times. (Rivka) Having a therapist who offers a different outlook at Yitzchak’s perceived “bad characteristics” and sense of failure by “calling it into question,” softens the overly harsh view of himself and self-concept.

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He showed me how some of my characteristics that I thought are bad, are actually a strength, and just because others might see it as a liability, we call that into question. It might be, but it might be a strength… I think it’s a really important thing for your readers to know about how helpful this is to therapy. People should know that there are probably plenty of things about themselves that for one reason or another overlook, or that they don’t see as strengths because they have had an interpretation of them as negative. Therapy with a good therapist might be an opportunity to work on this with someone else who can see this much differently and show how it might not be so negative after all. (Yitzchak) The ability to selectively attend to and amplify a strength embedded in a challenging situation is helpful for Yaakov, “because it has changed the way I think about myself in many instances, and that I should be proud of my efforts and motivation.” The therapist’s ability to locate a strength in such challenging situations reignites Yaakov’s self-confidence, and has positive ramifications both inside and outside the consulting room.

When I think about this, I think what was really helpful was him not losing confidence in my mailos [strengths]. He pointed that out to me and that was really helpful for me not just then but throughout the therapy we’ve been together.

(Yaakov) Emphasizing patient strengths is not a new idea and has its roots in both psychoanalytic and social work theory (Ornstein & Ganzer, 2000). Conceptually, the shift

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from focusing on patient’s deficiencies or problems to strengths and resources is most closely aligned with the strength-based practice, a well established perspective within social work literature and practice (Berg & Kelly, 2000; Cash & Berry, 2002; Cowger, 1994; Scerra, 2011). Drawing on the humanistic approach (Manthey, Knowles, Asher, & Wahab, 2011), strengths-based practice has been conceptualized as an overarching perspective, formalized into a set of practice principles during 1980s (Rapp, Saleebey, & Sullivan, 2005). Included in these principles are the idea that every individual has strengths, and that challenges, struggles, and conflicts can be reframed as sources of change and opportunity (Saleebey, 2006).

Implicit in the promotion of the strengths perspective is a critique of the psychodynamic model as being a deficit-oriented approach to assessment and treatment.

This critical view is due in part to conflating the medical model of psychiatry and psychodynamic theory. Equating a psychodynamic approach with a deficit model however, presents a limited characterization of psychodynamic theory and practice and does not take into account relational perspectives, which are compatible with the strengths perspective. Indeed, Ornstein and Ganzer (2000) examined the work of several major proponents of the relational approaches, including self psychology, and argue for its compatibility and integration. They conclude that as an overarching perspective, the strengths model can serve as an augmentation to enhance relational approaches.

Starck’s (2008) study as well, found highlighting strengths a curative factor identified by Orthodox Jewish patients. The participants in her study felt that by

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highlighting their strengths the therapist helped to broaden their perspectives, provide hope and motivation, and create positive meanings through reframing and metaphors.

From a self psychological vantage point, why might the highlighting of strengths be so meaningful for patients? The accounts of two of the four participants point to a struggle with low self-esteem and poor sense of self. Sara states: When I came into treatment, I knew very clearly what issues I wanted help with.

My low self-esteem and how I viewed myself and things like that… You know, self-esteem kind of stuff. And at such times she is able to point out the strengths and the abilities that I have. It is really helpful for me and building my self-esteem back up. (Sara) Sara’s tendency is to be hard on herself, which generates feelings of doubt and guilt and prevents her from viewing herself positively. Similarly, Yitzchak views himself as a “failure,” a “fake,” and “not a good person” in both, his eyes and in the eyes of God. Because my marriage ended in divorce. So, I must’ve told myself at one point, maybe came to a decision in my head or something like that, that I have no right being with people. I’d meet someone and get along fine, more than fine really, and I’d tell myself “who are you kidding? You’re not fit for friendship, you aren’t a really good person. Your divorced, Hashem [God] has taanos [complaints/indictments] on you. (Yitzchak)

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In a discussion about the etiology of low self-esteem Kohut (1984) writes: “disturbed self-esteem is a pathological state with genetic roots in the flawed mirroring responses of the selfobjects of childhood (p. 214).”

At the core of low self-esteem is a feeling of being unmirrored, alone, separate, and apart from. Within the therapeutic relationship, this plays out in the mirroring transference which includes all the conscious and unconscious manifestations of the grandiose self’s need for confirmation. In this way, assisting patients to discover abilities and strengths provides them with affirmation and structuralization of the grandiose self and its selfobject need of mirroring. In the mirroring dimension of the transference the patient’s experience of his therapist’s responsivity becomes symbolically elaborated as a relationship with an admiring or affirming other – in that the therapist finds me desirable and so forth. Consequently, highlighting strengths in all its varied forms, allows for good feelings about a self conceived of as being good.

I think it’s a really important thing for your readers to know about how helpful this is to therapy. People should know that there are probably plenty of things about themselves that for one reason or another overlook, or that they don’t see as strengths because they have had an interpretation of them as negative. Therapy with a good therapist might be an opportunity to work on this with someone else who can see this much differently and show how it might not be so negative after all. (Yitzchak)

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Summary.

While self psychology and psychodynamic therapy in general focus on deficits or pathological organizations of self-experience, participant accounts point to the beneficial therapeutic influence that identifying and utilizing strengths, abilities, and assets can have on the self.

Saleebey (1996), in a discussion about the benefits of the strength-based perspective, notes the significance of being mindful to the cultural dimension of certain patients and how it may be utilized for the revival and renewal of energies and possibilities. This has wide ranging implications for the practitioner treating the Orthodox Jewish patient. Such a transcultural type therapy could serve as extremely important sources of strength for the Orthodox Jew and include stories of culture, narratives or Jewish wisdom. Rabinowitz (2000) as well discusses how traditional Jewish thought can be incorporated into psychological treatment and used as a source of healing. For example, unlike the doctrine of original sin, Judaism not only emphasizes the belief that humans enter the world virtuous and pure, but should one stray, they can recapture such a state through the teshuva [repentance] process. Incorporating this familiar concept into psychological treatment can be useful in mitigating despair and promoting the ability to change (Zedek, 1998). Similarly, personal and familial stories of failure and redemption, struggle and resilience can be used as tools for inspiration and rebound. In addition, many classical Jewish works emphasize the cardinal Jewish principle of joyousness in the service of God, which can be accentuated to help motivate treatment compliance with a

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depressed patient as well as encouraging psychological and emotional well-being.

Finally, no different than the “survivor’s pride” possessed by people who have overcome abuse and trauma, a focus on cultural strengths can tap into the deep Jewish pride which might be buried under the shame and guilt Orthodox Jewish patients often feel about needing therapy for their challenges.

In sum, integrating the strengths based perspective with psychodynamic relational theories, can provide a comprehensive approach when working with the Orthodox Jewish patient. Attending to the inherent strengths of the Orthodox Jewish patient serves as a crucial mirroring selfobject function and benefits the grandiose self. This in turn can increase the perception of abilities and is likely to elicit and foster hope (Rapp & Goscha, 2006) the final subtheme of this paper to which we now turn our attention.

Climate of hope.

The idea of hope as a beneficial psychotherapeutic factor has been addressed to some degree in the literature. Research participants appear to respond positively to a wide array of hope-producing initiatives that lie on a continuum from the more explicit interventions aiming directly at instilling hope, to therapeutic encounters that appear to generate hope in much subtler ways. Thus, speaking to the fact that there is not a “onesize-fits- all” hope-inspiring therapeutic process. While all participants recognized the beneficial aspect of hope, they differed somewhat in their constructions, highlighting a multifaceted understanding about the construct of hope. Speaking to an interpersonal

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process of hope (Farran, Herth, & Popovich, 1995), Sara describes how her therapist’s conviction in her self-efficacy was influential for the restoration of her own belief in self, seemingly lending support to the idea that hope is fostered within caring therapeutic relationships.

Baruch Hashem, from the very first session it was such a relief for me, like a huge burden was taken off my shoulder. She’s wonderful and more importantly, she cares and believes in me, which in turn has restored my belief in myself, given me confidence, you know? It’s good. I really look forward to our sessions. (Sara) Similarly, Rivka describes how her therapist’s acknowledgment about the legitimacy of the depth of struggles and her feelings, while at the same time maintaining hope in a caring and attentive God, was significant in activating her own sense of hope.

In Rivka’s case it appears that the instilled hope has undertones of a spiritual element whereby hope is linked to faith.

So, what can she give me? What does therapy offer? And she tells me that she has hope for me! She believes that there’s Something and Someone that is above this world and reality and that she believes that He hasn’t forgotten me. So, I’m handling my challenges because of the faith and confidence she has in me and Hashem. So yes, I believe it’s, hope that is, it’s contagious! (Rivka) Both these participants experience hope because of the hope and confidence the therapist had in them. Such an idea is substantiated in the research. As early as 1959, Frankl’s “transcendent hope” (1959) principle found that holding hope for and offering

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help to others assisted the hoper in recapturing lost hope. Such behaviors were seen as providing people with a sense of meaning and purpose in life. More recently, Harris and Larsen (2008), offered further support that one’s hope is fostered through the hope held for others as well as in the context of relationships. Hanna (2001) states that a therapist’s positive expectations of a client can be highly influential on the client’s success in therapy and goes so far as stating a therapist’s confidence is contagious. In this way, very similar to Rivka’s statement, Hanna believes that hope is contagious.

In contrast to Sara and Rivka, Yitzchak’s experience of hope is a more rational construct, where his therapists reframe facilitated a change in perspective, resulting in a more hopeful attitude and increased sense of empowerment.

A lot of our time was spent on looking at some of my behaviors and trying to understand them in a more helpful way… It took time. But I never thought of it like that. Basically, the idea of what I thought was a negative behavior, as a skill… And I’m happy to say it, my life is more hopeful now. (Yitzchak) Yaakov’s experience speaks to meeting of minds between therapist and patient which allows hope and possibility to be transferred to the patient.

And being able to meet a person, meaning my therapist, who was able to look at things with me in a way that gave me the belief that things can be different, that is really helpful… Not to be me’yahish [hopeless], yiyush [hopelessness] is mamish [really] the end of things. (Yaakov)

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The participants varied ways of experiencing hope is supported by the literature as well, which places hope within a dynamic construct. For example, Farran and colleagues (Farran, Herth, & Popovich, 1995) provide a comprehensive description of hope that include an experiential process, a spiritual process, a rational thought process, and a relational process. Thus underlining its complex nature that will develop in different ways for different patients.

Within psychoanalytic literature and theory, there are several differing theoretical approaches to hope. Those following the Freudian contention that religion is “the institutional embodiment of infantile hopes and illusions,” see hope as a primarily regressive tendency, similar to fantasy and illusion (Mitchell, 1993, p. 205). On the flip side of the equation, Erikson highlights the constructive aspect of hope, considering it “the most basic of the vital virtues which begin to animate man pervasively during successive stages of his life” (Erikson, 1968, p. 233). And Kohut who assigns greater significance to hope than other analysts (Bergmann, 1987), perceives the idea of hope as a “necessary illusion that vitalizes self-experience, providing the motivation to persist in the face of despair” (Levine, 2007, p. 297).

Where is the concept hope most illuminated or expressed within the model of self psychology? In a discussion about Kohut’s foundational construct of selfobject transference, Ornstein (2008) notes the duality of the selfobject transference. On the one hand the patient’s experience and behavior reflects the insufficiently or faultily structuralized self, but “this transference also expresses (albeit often camouflaged) the

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“tendrils of hope” [Kohut’s term] to strive to repair the deficit; to reach out to the analyst with this hope for the responsiveness earlier denied (p. 202).” Ornstein feels that the latter dialectic of hope serves as the therapist’s strongest ally in the treatment process and left unrecognized or glossed over will obstruct any treatment effort.

Lastly, a word about culture when examining the integration of hope into therapy.

Averill and colleagues (Averill, Catlin, & Chon, 1990) conducted a study to explore the meaning of hope in the United States and Korea and based on their findings concluded that hope cannot be understood apart from its sociocultural context. For example, there are differences between the Eastern and Western perspectives on hope. From an Eastern perspective hope is an enduring personality trait, whereas in the Western world it is viewed as an emotion (Averill & Sundararajan, 2005). Consequently, the influence of culture on the meaning and experience of hope has special regard to the Orthodox Jewish patient and therapists should make a concerted effort to be culturally competent and sensitive to the unique values and needs of this population. And while a discussion about the Jewish perspective of hope goes beyond the purview of this paper, suffice it to say, that attending to cultural background when studying the development of hope in the context of therapy is imperative.

Summary.

Participant accounts attest to the crucial role instillation and maintenance of hope plays in treatment. From a self psychological perspective, hope in the therapeutic

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experience, whether by strengthening and empowering the patient, the therapist’s positive expectations of the patient, simply believing in a patient, reframing negative behaviors as skills, or converting a threat into a challenge, can be empowering and enhance the patients sense of self while at the same time can lead to greater integration and consolidation of identity. The literature discussing hope has highlighted the importance of considering the culture and ethnic orientation of each patient when working with hope.

Therapists must be keenly aware of these cultural factors at play and need to pay close attention to possible biases about cultural definitions of hope. LeMay, Edey, and Larsen (2008) offer examples of culturally sensitive questions therapists could use to explore the individual cultural influences of each patient including: (a) what can you tell me about your family or culture to help me better understand your hope, (b) what does hope look like in your family or culture, and (c) what does hopelessness look like in your family or culture?

In sum, hope begets hope and its transfer from helper to patient is possible (Snyder, 2000), and therapists should by no means be above exploiting this factor (Yalom & Leszcz, 2005). It seems appropriate to conclude this section with a twist on the Talmudic statement: “Where there is life, there is hope.” From the literature, research, and participant accounts the inverse would appear accurate as well: “Where there is hope, there is life.” Hope may help some to live longer, but it will help all to live better (Lamm, 1995).

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Chapter Summary This chapter discussed the findings as previously presented in Chapter IV, placing them within a wider context with reference to the selected literature, as per IPA (Smith, Flowers, & Larkin, 2009). The results were expounded upon through a self psychological perspective and a summary with implications were provided. The concluding chapter of this study will provide detailed recommendations for the study’s major findings.

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Chapter VI Conclusions The purpose of this phenomenological study was to explore and identify the specific beneficial factors of the psychotherapy situation from the vantage point of the Orthodox Jewish patient, as a means of enhancing the therapy experience for both clinicians and the members of the Orthodox Jewish community. The following sections highlight the major findings which emerged as exclusive to the Orthodox Jewish patient and provides conclusions and recommendations that follow and address four areas: 1. Ultra-Orthodox Jewish identity and its impact on the therapy experience 2. Ultra-Orthodox Jewish identity and the treatment process; 3. Ultra-Orthodox Jewish perspective on the therapeutic relationship; and 4. Ultra-Orthodox Jewish perspective on helpful therapeutic factors

Ultra-Orthodox Jewish Identity and Its Impact on the Therapy Experience The first major finding in this research is the unqualified reminder of the significant and inseparable role religion plays in the “self� and character of the Orthodox Jewish patient and consequently the therapy experience. A conclusion to be drawn from

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this finding is that this aspect of their identity will inevitably play a prominent part of, and in some way or other seep into the treatment irrespective of the original problem.

Therapists should not make the mistake of dismissing the need to introduce and discuss certain topics, practices and issues relating to Judaism as a form of avoidance, resistance or disavowal of reality.

Ultra-Orthodox Jewish Identity and The Treatment Process The second major finding in this research is the integral and beneficial role in which the therapy milieu and process has in creating a shared and common frame of reference for the Orthodox Jewish patient. The conclusion to be extrapolated from this finding is that there are many seemingly trivial cultural details which the practitioner should be mindful of, to help Orthodox Jewish patients feel more comfortable in therapy sessions and which contribute to a positive therapy experience.

The third major finding in this research is that for the Orthodox Jewish patient stigma and its dire repercussions are undisputable. A conclusion to be drawn is the therapist’s responsibility to be aware of this cultural reality and work hard to provide a safe, secure, confidential therapy milieu that is considerate of, and which incorporates specific safeguards that protects the integrity of the Orthodox Jewish patient.

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Ultra-Orthodox Jewish Perspective on the Therapeutic Relationship The fourth major finding in this research is that Orthodox Jews come into therapy with a cultural-based anxiety relating to the feelings about the therapist-patient relationship. Within the therapeutic relationship they appreciate being seen as a peercompanion and as being valued and respected as an individual, not a subject to be analyzed. The conclusion to be made from this finding is how imperative it is for practitioners from all theoretic schools of thought to be mindful how their training and perspective of the therapist-patient dyad might impact the relationship with Orthodox Jewish patients.

The fifth major finding in this research is the research participants’ understanding and experiencing boundary crossings as valuable. Ordinary everyday human courtesies were not considered to undermine the success of treatment nor perceived as compromising the therapist’s professional qualities. The conclusion to be drawn is that despite therapist training, knowledge, technique or theoretical and religious orientation, establishing a flexible and freer atmosphere may contribute to the building of the therapeutic relationship.

Ultra-Orthodox Jewish Perspective on Helpful Therapeutic Factors The sixth major finding of this research found that compared with their ModernOrthodox or middle-of-the-road counterparts, the Ultra-Orthodox Jew might feel that

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seeking out treatment with a culturally matched therapist would be more beneficial and achieve better treatment. A conclusion drawn from this finding is that professionals must provide an integrative treatment which includes a religiously-syntonic dialogue whereby the Orthodox Jewish patient can comfortably discuss Hashem [God] and other Jewishrelated material.

The seventh major finding of this research found that for the Ultra-Orthodox patient, therapist training, theoretical orientation and discipline is not a determinant nor plays a role in what they consider helpful in treatment. So that, despite the numerous factors identified by research participants, the role of theory, therapist theoretical orientation/training (psychodynamic, cognitive-behavioral etc.,) and discipline/degree of therapist (social work, psychology, mental health counseling, psychiatry) were notably absent from identified beneficial factors. One conclusion to be drawn is that perhaps all forms of psychotherapy are possible with Orthodox Jews and in the literature to date, psychodynamic, cognitive, and behavioral psychotherapies have all been utilized with positive outcome (Margolese, 1998). A second possible conclusion; due to the insular nature of their cultural upbringing and ideals (not college educated), Ultra-Orthodox Jews are unfamiliar with the different disciplines and schools of thought, and typically choose a psychotherapist by referral and word of mouth.

The eighth and final major finding in this study is that while some of the identified beneficial factors may not necessarily be distinguishable from those deemed therapeutic by non-Orthodox or non-Jewish patients, due to the unique cultural makeup

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of the Ultra-Orthodox Jew, including being more prone to feelings of shame, misconceptions about psychotherapy and its practitioners, there is a qualitative difference to how these factors benefit the Orthodox Jewish patient than other psychotherapy patients. A conclusion that can be extrapolated from this finding is that it is necessary for clinicians working with the Orthodox Jewish patient to not lose sight of the unique cultural factors that inhere the moment to moment interaction process and to not minimize making use of what the Orthodox Jewish patient finds helpful.

Recommendations for the Non-Orthodox or Secular Therapist Based on my findings, in cross-cultural or sub-cultural treatments, therapists are encouraged to: 1. Develop flexibility in working within the particular religious framework, and to not directly challenge the patient’s beliefs, unless they are clearly outside the realm of Jewish law and in collaboration with rabbinic consultation.

2. Develop a knowledge and understanding of the Jewish traditions, how mental health issues affect them, and how to work within the context of UltraOrthodox communities.

3. Increase familiarity about customary styles of communication and language among the Ultra-Orthodox. These might include quotations from the Bible or

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the Talmud, knowledge about upcoming Jewish holidays, and correct usage and pronunciation of Jewish terms and words.

4.

Develop sensitivity and knowledge about religious beliefs and behavior guidelines, including respectful comments concerning religious luminaries, avoiding unnecessary eye-contact with Ultra-Orthodox women, shaking hands with Ultra-Orthodox men, and manner of dress.

5. Be aware that for the Orthodox Jew, the words of King David, “I have set the Lord before me always” (Psalm 16) are central to his/her being. Ogden (1989) speaks about the concept of the “the analytical third” or the entity created in the encounter between two people, so that “when there are two there are three (Levinas, 1982, p. 14).” When considering the Ultra-Orthodox Jew there is also the concept of the “first,” that is, Divine authority. The practitioner has to understand that for the Orthodox Jew the authority of God takes priority over any human and interpersonal contact. In addition to this ever present Divine “first,” there is also the “third”; Halachah and human authorities in the religious hierarchy. The voices of Halachah, rabbinical authority and tradition are all present as concrete value entities of considerable impact. The therapist must respect and be open to working with all of these “presences,” and not make the mistake of thinking of himself as the authority.

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Recommendations for the Ultra-Orthodox Therapist In addition to the above recommendations, Ultra-Orthodox therapists are encouraged to: 1. Be mindful of haimishness; its influence on the therapeutic relationship and ability to compromise the therapeutic frame and one’s level of professionalism.

2. Exercise vigilance concerning the religious factor in transferential and countertransferential reactions by engaging in personal therapy and/or supervision. Spero (1985) states that God and the rabbinic authority are projected in the transference process onto the religiously observant therapist.

Furthermore, the unconscious and unspoken demand is for the therapist to be a rabbi, arbiter and guide. Inadequate self-awareness can lead to potentially harmful countertransference reactions (Spero, 1995).

3. Avoid fishbowl therapy (Wikler, 1990) by maintaining a strict code of confidentiality.

Recommendations for Schools of Clinical Social Work Based on my findings, clinical schools of social work are encouraged to:

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1. Develop a multicultural course within the curriculum regarding the specific social, familial, and cultural norms of Ultra-Orthodoxy and how it differs from general Judaism. This could include a psychodynamic understanding and conceptualization of treatment for the Orthodox Jewish.

2. Offer open dialogues which address the defensiveness in the psychoanalytic/dynamic community and overall tradition about God/religion/spirituality and its role in clinical practice. This could include introducing perspectives such as Frankl’s ‘spiritual unconscious’ which includes drives and impulses as well as spiritual elements (1986).

3. Invite Orthodox-Jewish practitioners and Rabbis as guest lecturers, to educate and answer specific questions about the community and the relationship between psychology and religion.

Recommendations for the Rabbinate As mentioned in Chapter II, Rabbi’s play a crucial role in the life of the Orthodox Jew and will often be one of the first sources individuals struggling with mental/emotional distress will turn to for help. It is critical therefore that Rabbis receive education, as a standard part of their pastoral training, in: 1. Learning about how psychotherapy can be a tremendous benefit and source of help for those struggling,

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2. Learning to appreciate the realities of mental health and human struggle including areas related to addiction, abuse, and trauma; 3. Learning to recognize their own limitations through an understanding about the areas in which they can help and the areas which is beyond their training and expertise.

4. Understanding the importance of collaborating with mental health professionals and assembling a list of therapists to whom they can make referrals.

Recommendations for Orthodox Jewish Community Activists Orthodox Jewish community activists or askanim, as they are commonly called, are on the front lines when it comes to matters affecting the community and can play a strong role in shaping and shifting misconceptions and behaviors regarding mental wellness and utilization. Community askanim then should seek, among other goals, to: 1. Create awareness of the role and benefits of therapy through community events, workshops, and presentations featuring mental health professionals.

2. As liaisons, assist in bridging the disconnect between Rabbis and mental health practitioners.

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3. Increase utilization of psychotherapy services through the creation of a fund which subsidizes the cost of good psychotherapy treatment for those seeking therapy.

4. Support establishments which seek to promote mental health awareness, such as organizations like Relief, Nefesh International, Amudim, and Keren Ezer L’nefesh.

Recommendations for Orthodox Jewish Persons Seeking Treatment Based on my findings, consumers should understand: 1. As the four participants of this study highlighted, psychotherapy is and can be helpful and life-changing.

2. While participants in this study were satisfied with their first psychotherapy experience and therapist, it is important to bear in mind that this is not always the case. Be patient and be aware that the process of finding a therapist who is suitable over the long-term can sometimes take time.

3. For the first time Orthodox Jewish patient, it bears keeping in mind that it might take some time to comfortably transition into the psychotherapy experience, whose interchange differs markedly than talking with a friend or even a Rabbi.

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4. Be open to educating the therapist about religious needs, sensitivities and considerations, especially within a cross-cultural or sub-cultural therapy situation.

Study Limitations In terms of limitations of this study, small sample size and lack of geographic variation serve as limiting factors. The sample size for this study was four participants which does not adequately ensure a representative distribution of the Orthodox Jewish population. That being stated, Smith et al. (2009) when reflecting upon the maturation of IPA, note how researchers are now adopting very small sample sizes, and even single case studies. They observe that the typical number of interviews analyzed in professional doctorate projects (between four and ten) “seems about right”, and that it is “important not to see the higher numbers as being indicative of better work” (p. 52).

Furthermore, the research sample was restricted to adults 18 years of age and older and is culturally limited to the Orthodox Jewish community. Consequently, it cannot generalize to child and adolescent populations nor does it provide adequate diversity for patients’ perspectives from a differing culture. Qualitative research however, does not seek to generalize findings rather its goal is to transfer to another particular context. In this vein, the findings from this study can further illuminate the topic of

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Orthodox Jewish practices, attitudes, and experiences with regard to psychotherapy, thereby adding to the research literature.

A second limitation, and one of the common critiques of qualitative research methodology in general, relates to researcher subjectivity and bias. As an Orthodox Jewish therapist who has undergone his own psychotherapy treatment, my own assumptions, interests, perceptions and views about the beneficial aspects of psychotherapy are sure to impact the findings and results. To this end, I acknowledged my biases and partialities by acting as the first respondent to this study, thereby allowing for transparency and the ability to communicate and separate my assumptions from the research and participant responses and data. Moreover, as discussed in Chapter III, ‘bracketing’, member checking measures were utilized applicable to IPA as well as reflexive journaling.

My lack of experience in performing qualitative research and IPA methodology presents a third limitation. Smith, Flowers & Larkin (2009) feel that inexperienced researchers are overly cautious and produce overly descriptive analyses. And while pilot interviews allow new researchers to gain comfortability with the interview process, assess researcher bias, and allow testing and further development of research instruments (Creswell, 2007), because of the shame, privacy and stigmatization associated with being a psychotherapy patient, I was unable to locate anyone outside of the research sample who would agree to be interviewed.

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As mentioned above, this study found that research participants gave no particular significance the theoretical leanings, interventions, or training, of their therapist, nor was it identified as a factor in their reflections. Additionally, participants made no mention of therapist degree, and were unsure whether their therapist was from the school of social work, psychology, or mental health. This finding is quite surprising given the importance we, in the professional community, place on theory, training, and discipline. The lack of mention regarding therapist training and discipline under which all of the noted beneficial factors emanated from, may be considered a limitation to this study’s overall findings.

After all, the immersive empathic stance of the self psychological trained therapist and his/her intervention differs markedly than say, the more experience-distant interventions of the cognitive-behavioral therapist. Instead of simply attributing such findings to a common factor model, or concluding that the therapist’s particular orientation, or type of therapy, was unimportant to participants, future research could develop criteria which include therapist orientation and training to better tease out the relationship, if any, between identified helpful phenomena and therapist degree, training, and theoretical orientation.

A final acknowledged limitation concerns this study’s exclusive focus on the perceived beneficial aspects of participants psychotherapy experience. That is, no data was obtained to indicate participants attitudes about the possible unhelpful aspects of their therapy experience. This decision was deemed preventative and necessary, particularly due to the stigma and potential negative feelings the Orthodox associate with

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psychotherapy. It was feared that engaging participants in subjective, in-depth discussion about what might have been unhelpful would revive feelings of guilt/shame thereby limiting subject participation and more importantly be potentially injurious to participants.

Recommendations for Further Research 1. Given the small sample size of research participants, a larger sample consisting of Orthodox Jewish men and women should be organized to ascertain whether similar or different findings will be discovered.

2. In addition, the current sample’s lack of geographic variation undoubtedly underrepresents the wide diversity of religious beliefs, attitudes, values, and commitment across Ultra-Orthodoxy, its diverse sub-groups and communities.

Future research using a larger and demographically diverse sample would be useful in order to understand the degree to which these findings may differ by Orthodox sub-group and location.

3. In this study both subject and therapist belonged to the same reference group.

Future research could include cross-cultural matched situations to determine whether the attitudes and findings in this study extended to that area as well.

4. Finally, given the information gleaned from this study, a natural progression from here would be to examine the non-helpful factors from the Ultra-

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Orthodox perspective. Such an undertaking would potentially provide a more robust picture of the Orthodox Jewish patient’s therapy experience.

Personal Reflections As I near the end of this paper, a project three years in the making, thousands of hours spent reading, researching, writing, thinking, and numerous ‘burning the candle at both end’ moments (hoping that it gave a lovely light, to paraphrase the late Christopher Hitchens), I am filled with a sense of pride, joy, relief, and gratitude to the Ribono shel Olam for providing me with the motivation, strength, patience and perseverance to see this project out from start to finish. This paper has been invaluable, perhaps even serving as a selfobject, in providing me with direction and purpose and with the completion of each chapter allowing me to look at myself with a feeling of confidence and expansiveness. Moreover, it enhanced my professional self by better conceptualizing and crystallizing the many factors and nuances involved in providing good treatment and becoming a better clinician. In that vein, as a psychotherapist and psychotherapy patient myself, I know firsthand the wonderful benefits and rewards of providing and receiving a good psychotherapy experience. I also know all too well, the feeling of desperation and despair that often comes as result of being stuck between craving help, while at the same time belonging to a culture where therapy is associated with stigmatization and branding.

It is against this backdrop that I express my tremendous, infinite sense of gratitude and

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thanks to Sara, Rivka, Yitzchak and Yaakov for having the courage to step forward, share their journey and experiences and allow me to partake in a very intimate chapter of their lives. Their willingness to collaborate, share of themselves and their time, speaks to their generosity of spirit and sense of responsibility to helping humankind. I am confident that their contribution to this study, will assist individuals – Orthodox or not, to take the leap of faith and venture into the wonderful gift we call psychotherapy.

Conclusion In conclusion, a great deal of knowledge and understanding is required when working with Orthodox Jewish patients. The narratives of the four research participants illustrate how the Orthodox Jewish patient brings a unique set of cultural beliefs, principles, practices, and community ecology to the therapy situation. There is a deep, powerful, and rich inner world which governs Orthodox Jewish thoughts, feelings, and behaviors. Psychotherapists who desire to work effectively with this group need to acquire a working knowledge about their traditions, how mental health issues affect them, and how to work within the context of Orthodox communities.

This research paper set out to promote knowledge of working with the Orthodox Jewish patient, inform best practice interventions for this population, and better understand how the Orthodox Jewish patient’s cultural identity inhere treatment. It posed four research questions that addressed these objectives, and subsequent findings shed

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light from a self psychological perspective on the therapeutic factors deemed beneficial from this population’s perspective. In addition, the research provided a summary of findings and followed up with associated implications, conclusions, and recommendations.

So, what are best ways and means of practicing psychotherapy? There are many.

And as Freud declared, “all that lead to recovery are good” (Freud S. , 1905, p. 259).

What are the beneficial aspects that encompass successful treatment? Once again, there are several, and Kohut reminds us: “there is no single analytic road toward cure – there are many, depending on the specific health potential of a specific analysand (Kohut, 1984, p. 44).” Nevertheless, the bedrock upon which this entire project rests is the notion that psychotherapy patients have what to say and offer. But they need to be asked, listened to, and their input considered seriously. It is my sincere hope that this undertaking and detailed description of the lived experience of these four Ultra-Orthodox Jewish patients will lead not only to a more enhanced therapy experience, increased sensitivity to the cultural interplay between patient and therapist, a greater appreciation between psychology and religion, and the de-stigmatization of those in need of therapy services, but also that the mental health profession will take notice of its patient population and seek out their thoughts and ideas about the clinical process. To work with the Orthodox Jewish patient, indeed with any psychotherapy patient, practitioners of the field must adapt to their worldview and culture, and not the other way around. In so doing, as participant narratives chronicling their therapy experience indicate, we can

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become more informed about the beneficial features of psychotherapeutic treatment and utilize this potentially powerful tool to further their personal growth and improved functioning.

Insofar as this paper was written with a heavy emphasis on self psychology, I feel it only appropriate to conclude with the words of the great Heinz Kohut, in the hope that his message will find its echo in the minds and hearts of the reader:

If there is one lesson that I have learned during my life as an analyst, it is the lesson that what my patients tell me is likely to be true – that many times when I believed that I was right and my patients were wrong, it turned out, though often only after a prolonged search, that my rightness was superficial and their rightness was profound. (1984, p. 93)

‫חזק חזק ונתחזק‬

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Appendix A Flyer

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‫כל ישראל ערבים זה לזה‬ YOU CAN DO A MITZVAH BY PROMOTING A GREATER UNDERSTANDING OF WHAT WORKS IN THE PSYCHOTHERAPEUTIC TREATMENT OF THE ORTHODOX JEWISH PATIENT – CURIOUS TO KNOW HOW? If you are 18 years of age or older and participated in weekly psychotherapy for at least six months over the past two years, I’d appreciate your volunteering for my research study which seeks to uncover what you found helpful about your particular psychotherapy experience and any additional thoughts you might have about this as an Orthodox Jew. This project, entitled: “The Beneficial Aspects of Psychotherapy: The Lived Experience of the Orthodox Jewish Patient,” is being conducted for dissertation purposes by Shalom Augenbaum, who is a doctoral student at The Institute for Clinical Social Work (ICSW) in Chicago, IL. Your kind assistance will aid in facilitating this study, and, IY”H make it into a rich source of useful data from which the frum psychotherapy consumer will benefit.

If you are interested in participating in this study, or if you’d like to receive additional information feel free to contact Shalom Augenbaum, LCSW, CASAC, with any questions or comments: email: shalom.icsw2012@gmail.com phone: 732-276-6168 All inquiries and aspects of this project will remain strictly confidential and is guaranteed throughout the entire process.

Thank you for your interest!

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Appendix B Pre-Screening Instrument

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PRE-SCREENING INSTRUMENT Name: _______________________ Pseudonym: _______________________ Date: _____________ Upon receiving phone calls from interested parties, the researcher will provide an overview description of the research by verbalizing the following script: Hi. My name is Shalom Augenbaum and I am a licensed clinical social worker. I understand that you have an expressed interest in participating in a study I’m conducting about the positive experiences of Orthodox Jews in psychotherapy. I’d like to tell you more about the study – and then, if you’re interested in participating, I’d ask you a few study-related questions to assist me in determining your eligibility as a participant and then with scheduling an interview time. This whole process will take no longer than 10 minutes. Is now a good time to do this, or would you prefer I call you back at some better time?

[CALL BACK #: _______________________________] − The study I am conducting will take an in-depth look at the experiences of frum Jews’ experience in psychotherapy. Specifically, I am interested in discovering what they found helpful and beneficial about their experience. I will be interviewing approximately 4 to 5 Orthodox people in total – all of whom have at some time been a psychotherapy patient. Interviews will be completely private and confidential.

Confidential means that your identity as a participant in this study will forever remain unknown. With your permission, the interview would be audiotaped. Then it would be transcribed by myself. The typed transcript will not include any names or other identifying information you may have mentioned in the interview. Each typed transcript will be identified solely by a pseudonym name assigned by me. − The interview would be conducted at a time and place of your choosing. It would involve my asking you questions that elicit information about: 1) demographics, 2) therapy history, 3) therapy expectations, 4) religious self-definition, 5) therapy process and outcome, 6) perceived benefits and 7) closure. You would be free at any time during the interview to end the interview, or, to skip any questions you don’t want to answer. My preference would be to audiotape the interview since a lot of information will be covered, and taping is the best way to ensure that I accurately and fully capture your responses.

Would you be comfortable being audiotaped during such an interview? ___YES ___NO - if no, thank them, explain why they would be unsuitable for this study.

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− The information gathered from the group of interviews will be analyzed to identify patterns and themes in the experiences of Orthodox Jews who have been in psychotherapy. Findings from the study can be used to promote a more effective psychotherapy experience and outcome for the Orthodox Jewish consumer; assist psychotherapists in being more sensitive to the needs of this minority population and hopefully assist in shifting the frum communities current view of psychotherapy to a more positive light. − The interview process might require two sessions lasting between 60-90 minutes. − Are there any questions you have about the study, or about participating, which I can answer for you? −

Can I count you in as a participant in the study? ___YES ___NO: - if no, “Ok, thank you for your time and interest. Be well and have a nice day.” ********************************************************************* ************ If YES: Great! Now I need to ask you a few quick questions (this should take under five minutes) to insure you meet the study criteria and if yes, to schedule your participation: 1. Do you currently identify as Orthodox Jewish? ___No: - if no, thank them, explain why they would be unsuitable for this study. ___Yes: Which of these categories most closely approximate where you currently identify yourself within Orthodoxy? ___Modern Orthodox; ___Yeshivish/Black Hat; ___Ultra-Orthodox; ___Chasidish; ___Something Else 2. Were you raised Orthodox? ___No: - if no, thank them, explain why they would be unsuitable for this study. ___Yes: Which of these categories most closely approximate the religious identity [outlook & lifestyle] in which you were raised? ___Modern Orthodox; ___Yeshivish/Black Hat; ___Ultra-Orthodox; ___Chasidish; ___Something Else 3. Approximately how long did you see your therapist for? ____________

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4. Approximately how recently did your last course of psychotherapy end – or is it going on right now? ____________ ************************************************************************ ********* SCHEDULING: 5. What would be the most likely days of the week and times of day when you’d be available for interviewing? ________________________________________________________________ 6. Where would you want me to come to conduct the interview? ___________________________ 7. That’s the end of my questions. Thanks for your time and assistance. I’ll be reviewing all this information from the different study volunteers, and then calling you back after I have an idea of the best times, logistically, for me to try to schedule people. If when I call you back you are not home, is it okay to leave a message on your answering machine? ___YES ___NO

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Appendix C In-Person Pre-Interview Script

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In-Person Pre-Interview Script Hi! Nice meeting you. Before we begin our actual interview, I want to review some of the points we discussed on the phone, so that you can be absolutely clear on every aspect of the interview procedure. After you are comfortable about understanding these procedures, I will have you read and sign a consent form, which details a lot of what I will be reviewing with you now.

As we discussed, I am conducting my research study on the Orthodox Jewish patients’ perspective about what they found helpful in their psychotherapy experience.

Once we begin the interview, I will ask you questions from the interview schedule that was emailed to you last week. These questions will focus on your psychotherapy experience and your Orthodox identity, as well associated thoughts and feelings.

Your participation in this study is entirely voluntary. I anticipate that this first interview will last between 60-90 minutes, and the duration of the second interview will be determined as needed. You have the right to refuse to answer or skip any question at any time during the course of our interview, and I encourage you to share information deemed relevant and safe to your emotional well-being and comfort.

As we discussed on the phone, with your permission, these interviews will be audiotaped using a digital recorder. Your participation in this study will be strictly confidential. Any personal identifiable information collected during the interview process will be kept strictly confidential and will only be viewed by myself. Under no circumstances will you be identified by your true name at any time during this research

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study. None of the recording, text transcription, notes, forms, or analysis documents will contain your true name. I will assign you a pseudonym name for the duration of the project, and all data and computer files will be identified through your false name. Once again, if at any point in time you feel distress and wish to stop the interview, let me know and we will stop until you are ready to resume.

Do you have any questions about what we just spoke about? Is there any part that is unclear? Are you ready to begin? If yes, please read the formal consent document.

After doing so I will ask you, the participant, to reflect back to me, in your own words, how you understand what this study is about as well as your rights as a participant. This ensures that I know that you have a complete understanding of everything we just spoke about and what you read in the consent. Specifically, to ensure your clarity about this study, I will ask you to verbally reflect back to me your understanding of the following: 1. This study includes participants who have been/are engaged in weekly therapy for at least at least six months and ended their treatment within two years of the study. You fulfill these criterions, correct?

2. Are you clear that the research is part of a dissertation study through the Institute for Clinical Social Work?

3. Please explain in your own words the purpose of the study so I know you fully understand what we are doing today.

4. Please explain in your own words the procedure used for the study.

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5. Please explain in your own words the benefits, costs and potential risks involved by being a participant in this study.

6. Please explain the privacy and confidentiality guidelines that I will follow.

7. Are you clear about who you can contact for questions or concerns should they arise?

Once that is complete, I’ll ask you to sign the consent and we can move on to the interview.

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Appendix D Participant Informed Consent

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Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research The Beneficial Aspects of Psychotherapy: The Lived Experience of the Orthodox Jewish Patient I, , acting for myself, agree to take part in the research entitled: The Beneficial Aspects of Psychotherapy: The Lived Experience of the Orthodox Jewish Patient.

This work will be carried out by the principal investigator, Shalom Augenbaum, under the supervision of his dissertation chair, Karen Bloomberg, PhD, and is in the service of the principal investigator’s work toward earning a PhD in Clinical Social Work from the Institute for Clinical Social Work.

This work is conducted under the auspices of the Institute for Clinical Social Work (ICSW); at Robert Morris Center, 401 South State Street: Suite 822, Chicago, IL 60605; (312) 935-4232.

Purpose The primary purpose of this study is to contribute to the existing general literature in the field of clinical social work by exploring in detail what a limited number of adult Orthodox Jewish participants say was beneficial about their specific and unique experiences in psychotherapy as well as to uncover the subjective attitudes and dynamics that inhere the frum patient’s treatment experience. While research focusing on the perspective of the psychotherapy patient has made progress in increasing our understanding of the benefits of psychotherapy and its effects, there have been virtually no studies which describe the beneficial aspects of the psychotherapy experience from the perspective of the Orthodox Jew. Increased knowledge in this area can promote a more effective psychotherapy experience and outcome for the Orthodox Jewish consumer; assist psychotherapists in being more sensitive to the needs of this minority population which ultimately may assist in shifting the frum communities current view of psychotherapy to a more positive light. By identifying these individual factors, engaging in psychotherapy with the Orthodox Jew can be a stimulating and productive endeavor for both therapist and patient.

Procedures Used in The Study & Duration

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After you have agreed to partake in the study your interview will be scheduled and the Interview Schedule containing the study questions will be sent to you one week in advance. Before beginning the interview, you will be informed on procedures, your rights and confidentiality safeguards. Once you indicate your understanding, you will be asked to read and sign this Informed Consent. You will be interviewed in person at least once; at maximum twice, at the location and time of your choice. The first interview will last between 60-90 minutes, with the duration of the second interview determined as needed.

With your permission, interviews will be audiotaped using a digital recorder, with audio files then transcribed by the principal investigator using a chosen pseudonym.

Pseudonymized transcripts of interviews will be shared between the study’s principal investigator, dissertation chair, and dissertation committee. Prior to your second interview, I will email you detailed themes and descriptions gathered from your first interview so that you may make note of any changes, comments, or questions you have regarding accuracy and clarity. This data will be sent to you via a password protected file.

Benefits While there will be no financial benefits for your participation in this study, the knowledge gleaned from your involvement can be used to educate and inform psychotherapists treating members from the Orthodox Jewish community how to improve delivery of services by learning about what supports and sensitivity might be therapeutically helpful for this population. Your participation will thereby enhance the psychological and emotional well-being of the frum psychotherapy consumer, resulting in the great mitzvah of assisting your fellow Jew. Costs There are no costs associated with participation in this study Possible Risks and/or Side Effects While there is a potential to experience positive reactions when discussing your psychotherapy experience, this research does pose an above minimal potential risk to you. Any such risk would be associated with possible recall or discovery of negative emotions and attitudes you hold with regard to your experiences in psychotherapy and identity as an frum Jew. There may be a risk that being asked personal questions about aspects of your psychotherapy experience as well as the reasons for being in psychotherapy may evoke feelings of being in a psychotherapy session. To mitigate that risk, before and at several intervals during the first interview the principal investigator will reiterate the purpose of the interviews as being solely for research purposes as a means of reminding you of the study as a research initiative and not psychotherapy.

You reserve the right to refuse to answer any question at any time during the course of the study, and are encouraged to share information deemed relevant and safe to your emotional well-being and comfort. If you feel uncomfortable at any point during the interview, the principal investigator will offer immediate support. This means that you can take a break from the interview, you can skip and come back to a particular question, or you can choose to not answer the question at all. You have the option of opting out of discussing any aspect of your experiences that you feel are too distressing. In addition, you may choose to leave the study entirely, at any time, without any consequences. If you

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no longer want to be in the study for any reason or want to immediately end an interview, referrals for professional therapeutic help will be provided at your request, and the principal investigator will provide you with a full debriefing.

Privacy and Confidentiality Your participation in this study will be strictly confidential. Under no circumstances will you be identified by your true name at any time during this research study, or in any publication thereof. None of the recording, text transcription, notes, forms, or analysis documents will contain your true name. You will be assigned a pseudonym name for the duration of the project, and all data and computer files will be identified through your pseudonym. A master list connecting your name with your pseudonym name, as well as consent forms with your name will be kept separate from the transcribed data in a locked file cabinet in the principal investigator’s home. The principal investigator will be the only person who can view data with your identifying information.

Data from the study will be coded and securely stored on the principal investigator’s private computer which is password protected and kept behind locked doors. Individual interviews will be digitally recorded and transcribed by the principal investigator after each interview. The digital recorder used for recording the interviews will be kept in a locked file cabinet in the principal investigator’s home when the recorder is not being used. The raw data generated in the interviews (i.e., the transcripts of interviews) may be viewed by the principal investigator’s dissertation committee. Files passed back and forth between the principal investigator and dissertation committee will be password protected and sent only through the Institute for Clinical Social Work’s email system.

The master list containing participant names, consent forms, and all raw data transcribed from the interviews will be kept in separate locked file cabinets in the principal investigator’s home for the period of five years following the principal investigator’s graduation, and will then be shredded and destroyed by the principal investigator. At that time, the digital recordings of the interviews will also be erased. Additionally, all electronic forms of data kept in a password-protected file on a password-protected computer will be destroyed.

Use of Results This research study is to be submitted in partial fulfillment of requirements for the degree of Doctor of Philosophy at the Institute for Clinical Social Work, Chicago, IL. The results of this study will be published as a dissertation and include verbatim extracts of your narratives that will be available for viewing by the general public. Any identifying information will be modified and disguised before publication. In addition, information may be used for educational purposes in professional presentation(s) and/or clinical publication(s).

Subject Assurances By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness.

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I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of the ICSW will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw.

If I have any questions about the research methods, I can contact Shalom Augenbaum at 732-276-6168; shalom.icsw2012@gmail.com or Karen Bloomberg, PhD at 312-9354240; kbloomberg@icsw.edu.

If I have any questions about my rights as a research subject, I may contact Dr. John Ridings, Chair of the Institutional Review Board; ICSW; at Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; irbchair@icsw.edu.

Signatures I have read this consent form and I agree to take part in this study as it is explained in this consent form.

Signature of Participant

Date

I certify that I have explained the research to and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward.

Signature of Researcher

Date

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Appendix E Interview Schedule

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1) Demographic Data 1) Can you tell me about yourself and your life right now such as demographics, relationships, and what motivated you to participate in this study?

(Prompts: Age? Current residence? Marital status? Family composition? Level of education? Occupation?)

Probes: − How do you describe yourself? − How would friends describe you? − What are your interests? − Current relationships? − Who or what has influenced you the most in your life? − Reasons you volunteered for this research project?

2) Therapy History 1) Can you describe your therapy history; what led you to seek professional help, your experiences leading up to seeking out a therapist, and the length/frequency of treatment?

(Prompts: What were the challenges? Motivation to seek therapy?)

Probes: − How did you address your problem, before entering therapy? − Was there anyone you had tried speaking to (to address the problem)? − Description of therapist? Gender? Personality? Character traits?

Ethnicity?

3) Religious Self-Definition 1) Can you tell me about your religious identity, the daily living experience of being an Orthodox Jew and how it impacted your therapy?

(Prompts: How long ago? Religious level of family of origin? What comes to mind about your identity?)

Probes: − What do you feel defines you as Orthodox? − How has your level of Orthodoxy shifted over time? − Do you ever encounter conflict or tension in trying to align your behavior and daily life with your understanding of Orthodoxy?

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− How has/did your being Orthodox presented while you were in therapy, or come up because of therapy?

4) Therapy Expectations 1) Tell me about your expectations for therapy: What did you go in looking for in your therapy? How did you expect seeing a therapist would help you?

2) When you first began in therapy, had you expected your religious beliefs, thoughts or practice to be in any way relevant to the issues for which you came?

5) Therapy Process & Outcome 1) Can you describe the specifics about your overall therapy experience and being a frum Jew, how it felt when sitting with your therapist and why you stopped tx?

(Prompts: Currently in therapy? Description of typical session? Satisfaction with tx? Goals of tx? Therapist style? Who spoke more?)

Probes: − Characterization of your relationship with therapist? − Was the therapy’s outcome [so far] in any way affected by your religious identity? − How has therapy experience influenced your life as a frum Jew? 6) Perceived Benefits 1) When thinking about your therapist and overall psychotherapy experience, what aspects are/were significant and helpful as an frum Jew? (Prompt: Techniques? Problem solving ability? Style? Personality? Relationship?

Routine? Safe place? Confidentiality?)

Probe: − One thing that stands out most when you think about your therapist? − One thing that stands out most when you think back to your therapy experience? − Did your therapist remind you of anyone?

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7) Closure 1) Before concluding, is there anything you would like to add which we have not already covered, or would like to clarify or return to which you feel I may have misunderstood?

2) How did you feel today about talking about all these issues, and also about the actual interview itself? How do you feel now, having completed this interview?

3) Are there any changes you feel I could make in this interview to make it better for future interviews?

4) Are there any questions you would like to ask me? May I contact you again for clarification, if need be?

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