Running head: LITERATURE REVIEW / SOAP NOTE 1

Literature Review and Cultural SOAP Note: Betsie

Elizabeth Cuttle

Department of Counseling, Wake Forest University

CNS 747: Cultures and Counseling

Dr. Michelle Ghoston

June 19, 2021

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Literature Review and Cultural SOAP Note: Betsie

Jewish Americans are both an ethnic and a religious minority group, and they face

distinctive challenges related to identity, assimilation, anti-Semitism, biculturalism, invisibility

as a minority, and interfaith marriages (Flasch & Fulton, 2018, p. 2). Jews have tended to be left

out of multicultural consideration in the counseling literature, as it “fails even to recognize the

notion of Jews as a culturally distinct group” (Schnall, 2006, p. 276). Moreover, Orthodox Jews’

mental health needs are poorly met, often only seeking help as a last resort when symptoms are

severe (Schnall, 2006). For these reasons, it is important to shed light on the myriad of unique

challenges faced by Jewish Americans and culturally competent counseling strategies.

In order to understand how to best counsel Jewish Americans, it is first necessary to delve

into Jewish values and culture-specific terms. First, counselors need to know “in most Jewish

traditions, the family is the key structure in the client’s life and that there are emotional

consequences for going against the wishes of the family (e.g., guilt, anxiety)” (Schlosser, 2006,

p. 432). Since the family is so central to many Jewish individuals, deviating away from the norm

can cause great distress. In a similar vein, counselors also need to understand the role sexism

plays in the Jewish community, in that women are required to maintain traditional gender roles

by primarily raising Jewish children. Deviating from cultural expectations – not having children,

remaining single, focusing on one’s career – are factors that can cause anxiety or conflict among

Jewish women and families (Ginsberg & Sinacore, 2013, p. 137).

As described in Betsie’s story, she experienced tremendous anxiety over finding a

husband, and she felt like she was a disappointment to her family. According to Margolese

(1998), “A culture-specific anxiety disorder, known as shidduch (matching) anxiety, has been

described among Orthodox Jews…The social stresses surrounding finding a ‘good match’ can be
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enormous, and shidduch anxiety can precipitate a hasty decision to marry” (p. 47). This type of

anxiety is unique to Jewish culture, and Betsie suffered from her perceived inability to find a

match. Moreover, Betsie also described stress related to the women’s movement in America; not

only was she expected to raise children and take care of the home, but also be successful in a

career “as a way for women to establish autonomy and enhance self-esteem” (Paradis et al.,

1996, p. 276). Jewish Americans place an enormous emphasis on the family, and because of

failing to uphold these cultural norms, Betsie experienced anxiety.

Although Jewish Americans experience unique challenges, such as shidduch, they still

face barriers in seeking psychological help. First, Orthodox Jews may be reluctant to seek help

because of the tremendous stigma attached to mental health issues in this cultural group (Schnall,

2006). Many Jews would rather seek help from a rabbi for social and emotional issues because

they do not want to be deemed crazy or insane for seeking professional help (Schnall, 2006).

This is also related to shidduch anxiety because “fear persists among Orthodox families that

mental illness will affect one’s marriage prospects and family functioning” (Flasch & Fulton,

2018, p. 9). Because of the stigma attached to seeking mental health help, Jewish Americans take

confidentiality quite seriously, so counselors need to pay special attention to this factor

(Margolese, 1998).

Cognitive behavioral therapy could be an effective counseling strategy to help Betsie

handle her anxiety. Studies have shown cognitive behavioral therapy to be useful in treating

anxiety in Orthodox Jewish Americans, and “they are helped to achieve their identified goals of

reducing their anxious or obsessive symptoms so that they can fulfill their community and family

roles” (Margolese, 1998, p. 44). CBT techniques that have been successful with Jewish

Americans struggling with anxiety include “relaxation training, problem solving, identifying
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thoughts / assumptions, identifying and restructuring cognitive distortions, acceptance,

mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness” (Rosmarin,

Bocanegra, & Appel, 2019, p. 680). Moreover, a culturally competent counselor should also

adapt the cognitive behavioral therapy to include various aspects of Jewish culture. It is often

necessary to modify approaches and interventions to fit the values and beliefs of cultural groups,

including the Jews (Flasch & Fulton, 2018). According to Rosmarin, Bocanegra, & Appel

(2019), culturally competent adaptions include the following:

(a) religious framing, in which CBT techniques are presented using religious idioms and

language to describe and explain established treatment concepts/approaches; (b)

harnessing religious beliefs to facilitate cognitive reappraisal and restructuring of

maladaptive thinking patterns; (c) religion-based behavioral activation, which involves

direct utilization of religious practices to modulate affective states; (d) psychoeducation

to demarcate distinctions between bona-fide aspects of religious life versus religious

symptoms which are manifestations of psychopathology that co-opt facets of religious

life; and (e) identification and validation of spiritual struggles (p. 681).

These adaptations display a high level of understanding and sensitivity of the Jewish culture,

leading to a healthy therapeutic alliance between the client and counselor. Overall, a combination

of cognitive behavioral therapy intertwined with adaptations specific to the Jewish American

culture could be a successful approach in handling Betsie’s anxiety, as it has proven successful in

prior research studies (Rosmarin, Bocanegra, & Appel, 2019).

In working with Jewish American clients, it is important to take steps to prevent

premature termination of counseling. First and foremost, it may prove helpful to include rabbis in

the treatment of Orthodox Jews. In some cases, referral by a rabbi is the only way that Jews will
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seek psychological help, and their rabbis’ involvement in the counseling process can “improve

both compliance with treatment and the patient’s comfort with the setting” (Margolese, 1998, p.

41). A rabbi can also be a great resource in helping a counselor to understand nuances of the

Jewish culture as it relates to counseling Jews (Schnall, 2006). Moreover, counselors should

“expect an unusually strong interest in confidentiality” (Schnall, 2006, p. 278). It is crucial that

counselors stress the confidentiality of services when counseling Jewish Americans. If they feel

as if their privacy is being compromised, they may decline future counseling services. Other

factors to consider regarding confidentiality include not scheduling Orthodox Jews for

consecutive sessions, referral to a remote clinic, and general flexibility with appointment times

(Schnall, 2006). One last consideration to prevent client drop-out is the avoidance of opposite-

sex seclusion (Margolese, 1998). It is against Jewish law to be secluded with someone of the

opposite sex, so careful considerations must be made in determining a comfortable counselor-

client fit.

Overall, Jewish Americans are both an ethnic and religious group that have been largely

ignored in multicultural counseling, leading to feelings of invisibility as a cultural group. This

cultural group faces many challenges that are specific to Jewish Americans, such as shidduch

(matching) anxiety, sexism, and feelings of guilt or anxiety stemming from deviance from

traditional Jewish cultural norms. Orthodox Jews attach a strong stigma to seeking professional

mental health help, and many would prefer to seek the help from a rabbi. The assurance of

confidentiality is of utmost importance because of the stigma attached to mental health. Further,

an effective strategy in treating Jewish Americans suffering from anxiety is cognitive behavioral

therapy. The goal of these techniques – such as relaxation training, mindfulness, restructuring

cognitive distortions, and acceptance – is to eliminate or reduce anxiety symptoms. It would also
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prove beneficial to modify the CBT to include relevant aspects of Jewish culture, such as

incorporating religious idioms and language. In sum, a culturally competent counselor should

strive to develop an appreciation for diverse cultures, including Jewish Americans. Gaining an

increased understanding for this cultural group can help counselors to better serve the needs of

Jewish Americans.
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Cultural SOAP Note: Betsie

6/16/2021. 2 p.m. (S) Spends considerable amount of time in counseling session recounting

family stories and history. Refers to herself as “100% Jewish.” Reports closeness of family

growing up. Reports grandparents gave her a “much romanticized notion of love,” possibly

contributing to her difficulty in finding a partner. Lack of self-esteem / confidence in looks also a

contributing factor. Grew up in multicultural neighborhood with diverse friend group. Grew up

in 1960s and 1970s and reports being influenced by the civil rights movement, the hippies,

Vietnam War, and women’s movement. Reports feelings of being hated by unspecified others

because of her Jewish ethnicity. Refers to her parents’ divorce as the “most traumatic event of

my life.” Did not marry until 44 years of age. Reports trying pot for the first time at age 12.

Reports smoking pot every night in college to cope with worry and anxiety of “ego shattering”

grades. After college, smoked pot every night for 10 more years to ease pressure of unsuccessful

career and inability to find a husband. Reports feeling pressure from family, smoked pot to avoid

dealing with it. At age 26, started dating a Catholic man who was abusive. Reports feeling happy

and relieved to have pressure off her to get married. Escaped abusive relationship and

subsequently attended battered women’s group. (O) Exhibits pride in ethnic background (“I am

100% Jewish”) and family history, evidenced by confident tone and open body language. Smiles

upon reminiscing about early childhood memories. Tearful when describing the loss of her

‘Nonny,’ whom she considers her greatest influence. Voice stammering, jittery when describing

perceived failure to uphold family expectations of success in college and failure to find a partner.

Avoids eye contact when disclosing prior pot smoking habits used as coping mechanism. (A)

Client’s presenting problem revolves around perceived failure to uphold Jewish cultural norms.

Client displays symptoms of unspecified anxiety disorder, stemming from familial pressure to
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get married and uphold traditional Jewish women roles. Shidduch (matching) anxiety is specific

to the Jewish culture. Client has a history of cannabis use disorder but is now clean. (P)

Cognitive behavioral techniques used in 6/16/2021 session. Specifically, client worked on

identifying and restructuring cognitive distortions to manage anxiety related to pressure to

uphold cultural norms. Included Jewish religious beliefs to facilitate the restructuring of

maladaptive thinking patterns. Rescheduled for 6/23/2021 at 2 p.m. Will continue to identify and

restructure cognitive distortions. Will also introduce concepts of acceptance and mindfulness to

help manage anxiety symptoms. Consider Jewish religious idioms and language to describe

approaches. Prognosis is strong, due to client’s overall optimism in managing anxiety symptoms.

Reassure client of confidentiality to reduce likelihood of drop-out.

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References

Flasch, P., & Fulton, C. L. (2019). Counseling Jewish Americans: Considerations for

practice. Counseling and Values, 64(1), 2–19. https://doi-

org.go.libproxy.wakehealth.edu/10.1002/cvj.12091

Ginsberg, F., & Sinacore, A. L. (2013). Counseling Jewish women: A phenomenological

study. Journal of Counseling & Development, 91(2), 131–139. https://doi-

org.go.libproxy.wakehealth.edu/10.1002/j.1556-6676.2013.00081.x

Margolese, H. C. (1998). Engaging in psychotherapy with the orthodox Jew: A critical

review. American Journal of Psychotherapy, 52(1), 37–53. https://doi-

org.go.libproxy.wakehealth.edu/10.1176/appi.psychotherapy.1998.52.1.37

Paradis, C. M., Friedman, S., Hatch, M. L., & Ackerman, R. (1996). Cognitive behavioral

treatment of anxiety disorders in Orthodox Jews. Cognitive and Behavioral

Practice, 3(2), 271–288. https://doi-org.go.libproxy.wakehealth.edu/10.1016/S1077-

7229(96)80018-6

Rosmarin, D. H., Bocanegra, E. S., Hoffnung, G., & Appel, M. (2019). Effectiveness of

cognitive behavioral therapy for anxiety and depression among Orthodox Jews. Cognitive

and Behavioral Practice, 26(4), 676–687.

https://doi-org.go.libproxy.wakehealth.edu/10.1016/j.cbpra.2019.07.005

Schlosser, L. Z. (2006). Affirmative psychotherapy for American Jews. Psychotherapy: Theory,

Research, Practice, Training, 43(4), 424–435. https://doi-

org.go.libproxy.wakehealth.edu/10.1037/0033-3204.43.4.424
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Schnall, E. (2006). Multicultural Counseling and the Orthodox Jew. Journal of Counseling &

Development, 84(3), 276–282.

https://doi-org.go.libproxy.wakehealth.edu/10.1002/j.1556-6678.2006.tb00406.x