Culturally sensitive help, Jewish perspective

In this chapter I (KML) will say something about my perspective on the topic in the title. I shall say why I think cultural and religious issues are important for those offering psychological help. I will not dwell on all the reasons, but will focus on one general issue – that of understanding and feeling understood. Finally – and the largest part of this chapter – I would like to describe some experiences from those working on the coal-face, of working with the provision of culture-sensitive services.

My perspective.

This bit is to tell you something about who I am and where I am coming from. I read recently that it was a good idea to do this before writing up qualitative research, but I can’t see why it can’t be done before writing about any kind of research, or indeed any kind of psychology, qualitative research or otherwise.

I am an orthodox Jew, strictly orthodox, and a common corollary of that is having a very large number of children. As the years go by, we have an increasingly large number of grandchildren. I am also an academic psychologist. I started off my academic career in the 1960s by doing a thesis on the relations between thinking and speaking, and particularly the question of whether the outcome of thinking was affected by talking about it. When I began teaching, I felt that I stood with a foot in social psychology, and a foot in cognitive psychology, and for many years I taught both. But I got softer and softer, or perhaps it was harder to find people to teach social psychology, so I began to teach more and more social psychology, and less and less cognitive psychology. Then my boss, the late Brian Foss, met a philosophy professor from Kings College (London), the late Hywel Lewis. Lewis was looking for psychologist to teach the psychology of religion, and I think I was the only psychologist that Brian knew who didn’t think religion was a meaningless word. So I began teaching the psychology of religion, and which got me interested in personality theory, including psychodynamic theory, and psychometrics, as well as doing the kind of research in which the researcher collects accounts of people’s experiences. I am still a bit confused about what personality is, and about what is being measured in psychometrics, but in spite of this  - or, more likely, because of this – I began teaching personality, and psychometrics. Meanwhile the number of my children grew, and I began wondering about Brown & Harris’s (1978) report that women with several young children to care for, were more vulnerable to depression.  The anthropologist, Jeanette Kupferman (1979) thought that strictly-orthodox Jewish women might be more cheerful in their lifestyle full of boundaries and rules, large families notwithstanding. I wondered who was right. Tirril Harris was very encouraging about the idea of doing a replay of the Brown & Harris Camberwell and Hebridean studies among orthodox Jews, and I was happy to get some funding for this work. This led me deeper and deeper into issues relating religion and mental health. As the younger children grew older, I began to write and publish more and more on different aspects of religion and mental health.

Cultural  and religious issues in mental health.

Why are cultural and religious issues important in mental health? 

Ideally I would like to start with some nice-sounding suggestions about spirituality, and the importance of profound religious feelings and spiritual awareness for psychological balance and adjustment.  I would not want to deny the importance of these feelings and states of awareness, and I have personally been involved in work which generally supports the importance of these, empirically (e.g. Loewenthal & Cinnirella, 1999; Loewenthal, Macleod et al, 2000). However the generally positive relations between religion and better mental health mask a range of very complex effects, not all of them positive (e.g. Schumaker, 1992; Loewenthal, 1995; Bhugra, 1996;  Pargament, 1997; Koenig, 1998). In particular, I would like to focus on a very big issue which I would like to illustrate with a series of vignettes:

A dying Hindu in a British hospital manages to get out of bed and lies on the ground. Harassed nurses rush to replace the patient in the correct place - bed. The dying victim becomes deeply depressed or agitated. The efforts being made by the Hindu to die properly are being thwarted by the uncomprehending medical staff. A “good death” involves lying on the ground (Firth, 1997).

“It (speaking in tongues) is comforting, and you feel it helps. When my child was very ill in hospital, I sat by him and spoke (in tongues) for hours, but very quietly, so that the nurses would not notice and think I was odd” (Christian man, quoted in Loewenthal, 2000).

Louisa, a cult victim rescued by her family, was suffering from "religious monomania". Louisa in (enforced) confinement (in a psychiatric institution) was depressed, but "...walked up and down singing what she termed praises, making use of no intelligible words". The Commissioners in Lunacy  declared that "...her extraordinary and irrational opinions on religion...were irreconcilable...with soundness of mind", but that apart from her religious opinions, she was competent, calm and rational (Schwieso, 1996) It is interesting that there were cults,  cult victims, and deprogramming attempts in the mid-nineteenth century).

Two controlled studies suggested that otherwise identical cases are likely to be seen as suffering from more serious levels of psychological disturbance, if the people described are said to be religiously active (Gartner et al, 1990; Yossifova & Loewenthal, 1999).

I am labouring the point. Years ago, a fellow orthodox Jew warned me: “You have to be careful of psychiatrists and psychologists and social workers. They can say that the kids are disturbed because they shockel (sway backwards and forwards as they are encouraged to do, when they study sacred texts). Social workers can say the mothers are neglecting the children because they see a sheitel (wig, worn by a married woman for reasons of modesty). They think the mother is spending her money and time on nonsense like wigs instead of  looking after her family properly”.  If you are Jewish you might be misjudged as neurotic or dysfunctional, simply on the basis of some normative piece of religious observance, and you don’t want this to happen.

To stop this happening, you might think about changing or hiding your religious practices. But suppose that changing or hiding would mean a loss of spirituality, a feeling that you had severed yourself from your spiritual roots, and were denying your essential identity and purpose. In Judaism, religious commandments are called mitzvot, and the Hebrew word has an ambiguity (through a similar Aramaic word). It also means binding, being close. So it would painful to change or hide those practices and beliefs which give spiritual satisfaction, feeling close to G-d, even if this means misjudgment by others. What else might one do? One might try to set up a liaison system with the medical and psychological and social services. This has been done, although no-one seems to have much evidence on the results. And one might set up culture-sensitive support services, using provision from within the community, drawing on outside expertise where possible (Bhui & Olajide, 1999). This has also been done, although – again - no-one seems to have much evidence on the results. Culture-sensitive support is politically correct, but how does it function and does it work? 

In the rest of this chapter I would like to describe some themes emerging from an interview study on culture-sensitive support groups serving the strictly-orthodox Jewish community.  What is this community?

The strictly-orthodox Jewish community in the UK

The Jewish community in the UK is tiny, estimated at less than one-third of a million. One way of categorising the differences in life-style within the community, is by level of religious orthodoxy. An unknown number are not affiliated to any synagogue, but it has been suggested that this unknown number might be quite small, because synagogue affiliation gives burial rights, and it is thought that most Jews want to ensure a religiously correct burial. Of those who are affiliated, about 15% are affiliated to a strictly orthodox group, 15% non-orthodox, and the remainder are affiliated to a centrist orthodox synagogue (Shmool & Cohen, 1990). The strictly orthodox will adhere closely to the religious laws regulating the observance of the Sabbath and holidays – for example not using motorised transport, or using electrical appliances. Dietary laws - for example the strict separation of meat and dairy products in the kitchen, and in eating, marriage laws – monogamous sex only, and no intercourse during and after wife’s menstrual period, education – the study of sacred texts and religious law, and a host of other religious guidelines regulating behaviour, from using the lavatory, to the heights of religious ecstasy, from the cradle to the grave - all mean that almost all strictly orthodox Jews find it impossible or very inconvenient to live outside one of the few enclaves in the UK. There are several such enclaves, all offering kosher butchers and grocers, a host of synagogues, prayer and study houses, schools, ritual baths, and many other services essential to the maintenance of Judaism in this form. Communities are quite close-knit, with many family and neighbourhood ties, as well as connections by marriage to strictly-orthodox communities in other parts of the world. Women may have very few dealings outside the community. Outside the workplace, the same is usually true for men. One striking feature which dominates the economic, social and emotional life of the community is the value placed on large families. Contraception is normally prohibited, and the married state is strongly encouraged – men and women are regarded as spiritually incomplete, literally “half-souls” unless and until they have found their soul-mate. The result is an average current family size of 5 (Loewenthal & Goldblatt, 1993). Families with ten or more children are commonplace. This can have striking effects, both beneficial and harmful, on the emotional wellbeing of the parents (Loewenthal, 1997a; 1997b), and of the children. Many of these effects remain to be studied. 

There are several strictly-orthodox enclaves in the UK: Manchester, North and North-West London, and Gateshead are the largest, and their streets are peopled with men in dark suits or caftans, black or fur hats, often bearded, and often escorting a quota of young children to school, synagogue, shops or the park. There are modestly-dressed women, the younger ones usually pushing a stroller and surrounded by a bevy of young children. There are distinctive shops, for example selling kosher meat or Jewish books. There may be signs of the festivals: for example in the autumn, leafy booths (sukkot) in yards and gardens and on balconies, in the winter, eight-branched candlesticks (Chanukias) in windows, and sometimes in public places. A typical house will have a respectable room lined with gold-lettered seforim (Jewish books), with a large table used for Sabbath and festive meals, used during the week for (religious) study. There is usually a large kitchen with two sinks (one for meat food, one for dairy food) and space for the family to eat and for children to play. Strictly orthodox families seldom or never eat away from home: most restaurants are not kosher, and those that are kosher are beyond the means of the normal strictly orthodox family. There might be an occasional visit to a relative or friends, but not too often – to entertain a family with say eight plus young children is not a simple undertaking. So, without remission, the mother has a major catering operation, several meals a day, sometimes eaten in shifts, for averages of around seven people, often ten or fifteen or more. Her work is never done, and she has to keep it going no matter how ill or exhausted she may feel. The unremitting demands do not go away just because she has given birth, or has flu, or has to help or visit an elderly parent who is suddenly taken ill. The floor may be cluttered with play objects and playing children. The bedrooms will be crowded, with sleeping accommodation and cupboard space for four or more children in each. The washing machine whirrs incessantly, and there are daily massive piles of laundry to be folded and put away. Children get bored, upset, start arguing, need help with homework, start doing something constructive but with dangerous or messy or destructive consequences. The telephone and the door bell add to the multiple demands, and life is one unremitting attempt to do many things simultaneously, to prioritise,  to assert that it is simply not possible to respond to all demands, to keep a measure of cool, to keep speaking pleasantly, to monitor and influence the spiritual, moral, intellectual, social and practical skills development of each child. To care for the welfare and wellbeing of each member of the family, including her own. To try to stop the house falling down or becoming irretrievably cluttered. To stop hoping that she will ever get a night’s sleep. To try to feed and clothe, house and educate eight or ten or fifteen people on an income more appropriate for a family of three or four. All this is religiously and socially encouraged. Each child is valued. But – like mountaineering – the costs and risks are high. 

I have written this last description from the woman’s perspective because it is my own. I have included it because it now seems to be important, in understanding a central issue for most of the support groups I am examining. As I write, I wonder how I coped when there were ten children at home, including several of pre-school age, and over twenty years of being pregnant, nursing, or both.  I wonder how I cope now, when most of them are married but keep closely in touch, and often come to stay with excited gangs of lively grandchildren. I hope it is apparent that coping is difficult, and that any extra demand could tip a very precarious balance. I am quite sure that the social and managerial skills required for bringing up and coping with a large family are completely different from those involved in dealing with an average-sized family. And it isn’t just coping with the physical chores: it is bringing up children and adolescents and young adults to the religious practices and the spiritual and moral values inherent in strictly-orthodox Judaism.

Culture-sensitive support groups: how do they work and how are they perceived?

I am conducting a study of culture-sensitive support groups serving the strictly-orthodox Jewish community in North London. Here live about 15, 000 Jews, in an ethnically and religiously diverse area falling within the London boroughs of Hackney and Haringey. To qualify as a listed community member you have to belong to one of numerous synagogues affiliated to the Union of Orthodox Hebrew Congregations. This involves being Shomer Shabbos (Sabbath observant) and adhering to the dress codes, and norms with regard to life style, kosher diet, education of children, prayer, marriage, and other matters.  

Communal charitable organisations have a long history in Judaism. These might provide meals for the sick, help for needy brides, support for families where the breadwinner has died or is disabled. More recently, particularly over the last decade, the community has seen a growth of organisations offering a less material kind of support – counselling, telephone help-lines, and support groups.  Many of the organisations offering practical services and information are saying that there is a need for situation-specific counselling and support, which they are now beginning to provide. 

While writing this chapter, I scanned the four weekly publications widely available in the community: two newspapers, and two magazines full of fascination for the social anthropologist, carrying nothing but advertisements for goods and services for the community. Each carried one or two advertisements for a charitable or support group. Advertising however is expensive, and the existing services cannot afford to advertise on a regular basis. They rely on a directory issued approximately yearly by one of the newspapers serving the community, and on listings in the Shomrei Shabbos telephone directories, listing the telephone numbers of community members, schools, synagogues and other religious institutions, businesses, and support services. Finally, there is word of mouth.

The current  Shomrei Shabbos directory lists several dozen support services, charitable organisations and social groups.  

I selected eight groups offering either general counselling and support services, or situation-specific counselling and support. I am interviewing a key informant from each of the groups, to discover their accounts of each group’s history and activities, problems and plans. I am also interviewing 24 randomly-selected members of the community being served by these groups, to learn how much is known about these groups, perhaps to hear some direct and indirect reports of experiences with these groups, and to learn whether community members would use their services. 

What follows is an account of some of the emerging themes. I have confined the quotations to material about three of the groups:

Chai: the word Chai means “Life”, and the group is a cancer support group offering information, a help line, counselling, alternative therapies, financial help for specific services, screening, and other services, in a culture-sensitive environment;

Ezer LeYoldos: the term means “help for women who have given birth”, and the group offers support to women who have given birth, in the form of meals, help with other children, and help with housework. Recently the group has expanded its activities to include counselling, courses in parenting skills, befriending,  advocacy, and links with a culture-sensitive childbirth preparation and labour support group.

Chizuk: the term means encouragement and support. This group offers support to orthodox Jews suffering from mental illness, and their carers. It organises care packages, support groups and drop-ins, hospital visiting and other services and activities, including some counselling.

From the service providers

A sense of urgency, and of dedication in the face of difficulties

 Almost all the groups were founded by women, typically initially one woman, often getting together a nucleus of two or three, with a sense of mission. Almost every group is an outcome of a critical experience, or a series of experiences. These gave birth to a feeling that the Jewish person is not comfortable, not fully understood, and not well enough supported, when she or he passes through this critical experience and receives support from someone outside the community, no matter how professional or well-intentioned:

(Chai) My mother suffered from a rare form of cancer. At the time I was a young woman with young children. I was the person most actively involved with my mother’s care. At that time there was very little information available (for the public, for patients, and for their families). Doctors did not want to talk. That was not the climate of the time. Feelings were not considered. Doctors were focused on the disease only. It was very hard to get information, and it was also very difficult to get appropriate practical support. I felt it would have been helpful for my mother to speak to someone who had experienced cancer, and who had survived, so that she could see that there could be light at the end of the tunnel. It was hard to find former cancer patients to come and speak to her, because many (former cancer patients) wanted to put it behind them. I remember her lying ill in bed, and saying, please G-d, when I get through this I will make it my business to go and speak to people. Jewish people… have feelings and problems to which other people could not relate. 

(Ezer LeYoldos)It began when a niece of (the founder’s, AZ) asked her for help: the niece was expecting her ninth baby, and she needed help. AZ realised that friends and family are often overloaded and cannot provide all the help that is really needed at such a time. So AZ started a group of ladies to send in freshly-prepared meals for the family for two weeks after the birth of the baby, and to send in cleaning help, and make childcare arrangements during the mother’s confinement, or when a mother is ill.

Each of these informants has a similar sequence of events:

Critical experience      realising that Jewish support would be helpful      thinks about setting up a support group     talks to others who are supportive      starts work on setting up the group.

This did not happen in a political and social vacuum. Very few such organisations were around ten years ago. In the early 1990s it became possible and desirable for culture-sensitive support groups to develop. The reasons for this are beyond the scope of this chapter to consider. Through the 1990s, terms like politically-correct, ethnic minority, culture-sensitive, empowerment spread into the lexicon, empowering those who wished to develop culture-sensitive support for ethnic minorities, endowing them with the politically correct kitemark. As well as social approval, there were occasional financial tit-bits: local authority funding, lottery grants, charity funding, and gifts from private donors. Never enough, but enough to make the co-ordinators feel that their venture is justified. But the struggle to make ends meet is a thankless one

Need for a culture-sensitive service

These, and all other informants, reflected concerns about feeling comfortable, feeling understood. The myriad specific ways in which potential misunderstandings might occur were potently expressed by the coordinators of  the support groups. Every single group is dealing with a huge load of culture-specific, spiritually-related values, assumptions, experiences, fears and other feelings.

(Chai) People remote from Judaism come in and feel more comfortable.  It is now accepted that each group needs its own specific care.  For example, Jewish patients before Rosh Hashanah (New Year) or other Yomim Tovim (festivals), may have feelings and problems to which other people could not relate.  Every ethnic or religious minority group needs its own support system.  Going back to roots gives a feeling of stability and comfort.  People walk in here and feel at home.  We cater for people across the religious spectrum but our standards are such that the strictly orthodox would feel comfortable, for example the strictest kashrus (dietary laws), tznius (laws relating to modesty, usually applied specifically to modesty in dress).  The patients don’t have to wander around not properly dressed.  There is a dress code for all staff in the centre so that they won’t offend anyone.

These concerns about dress are not “just” about being prudish, old-fashioned, up-tight. This informant is telling us of one of the many practical ways in which a culturally and religiously-sensitive support group helps clients to feels comfortable. Clients may not even be aware of the efforts that have been made. But these efforts enable clients to escape the discomforts of acting as an awkward patient, of being judged as difficult and prudish, when asked to wear religiously unacceptable hospital gowns which (for example) don’t close properly, or don’t cover the arms.  The orthodox Jew genuinely feels positive spiritual value in modest dress, in treating the body with respect, in dealing with body as a means of expressing holiness. But it is difficult to communicate this in the context of the pressured hospital environment.

Ezer Leyoldos deals with the problems of mothers with large families trying to recover from childbirth, or to weather an illness that might be trivial if she could take it easy for a day or so. But she can never take it easy.  I have first-hand experience of the problems, and time and time again I, my friends, my daughters, and countless others, have felt that the statutory service workers  –  nurses, doctors, midwives, health visitors, social workers, and other experts on child care – have totally failed to grasp the quality and enormity of the tasks faced by mothers of large families.  At the same time, I have found it very hard to communicate why we do it. It is as if the “outsider” is saying: “ If it is so hard, why do it? If you want to do it, you must see a purpose in it, and that somehow makes it easy”. The believing Jew (and believers of other religious traditions) feels that each soul that is brought into the world into a human body is precious; each has spiritually significant tasks to accomplish; the parents are privileged to be the means of enabling this. But it is still difficult.

It is difficult to communicate with someone who is not familiar with the spiritual values and assumptions that underly child-bearing and child-rearing. Each child is precious, a spiritual gem. Outsiders might think the system is crazy. Just learn to use contraceptives, limit your family to a level that you can cope with. They do not understand. They might think I am crazy. Or bigoted. Or narrow-minded. Or ignorant. Or oppressed. Even if they said nothing, I might think that they were thinking those things. They could not really listen. I would not feel comfortable or understood. 

(Ezer LeYoldos) From the cultural point of view, patterns of crises among orthodox Jewish children and families differ from patterns in wider society. Most crises involve childbirth or illness, i.e. when the mother of a large family is not available. Illness is a crisis which does not affect just one or two people, when a parent is affected. We are holding up many people, by providing support during illness or at the time of childbirth.  We try to catch crises before they become irreversible. It is a huge investment to hold a family together, in order to build stable citizens. 

Every single one of these support organisations deals with myriads of interlocking behaviours, values and assumptions that – it is felt – could not be readily explained to outsiders. If we tried to explain our feelings and our problems, they would not understand. Or we feel they would not understand. 

Confidentiality

“We live in a goldfish bowl” said one participant. Perhaps an aquarium, where the dwellers in each glass bowl can watch the goings-on in the other bowls. There is stigma associated with every one of the issues which the support groups have been set up to deal with: cancer, coping – or failing to cope  - with family demands, stress, mental illness, loneliness…several authors have described the orthodox Jewish woman’s wish to see herself as the perfect baalabusta (mistress of the household), always cheerful, warmly welcoming and hospitable, immaculate home, well-behaved children, all healthy and doing well in their spiritual and moral and interpersonal development, who manages to run the home and support the family, while enabling to husband to engage in prayer and religious study (Goshen-Gottstein, 1992; Loewenthal, 1998). It can be hard to admit to deviations from this ideal, this picture of perfection. It can take some courage to seek help. 

(Chai) The strictly orthodox are very worried about confidentiality.  Some clients will only give their first names. They may not feel comfortable in our support groups (because they are seen and can be recognised by other people).

(Chizuk) One problem is stigma, and the related problem of confidentiality. In a small closed community like this, these are difficult issues. There is a lack of suitable venues. It is important that clients do not have to go buildings where it is obvious why they are going.

The issue of confidentiality may be the biggest problem faced by culture-sensitive support groups. I and my colleagues have certainly heard strong concerns about this issue from other minority groups (Cinnirella & Loewenthal, 1999; Loewenthal & Cinnirella, 1999). How can you provide support and understanding from within the community, if your clients are afraid that “everyone” will get to know that they are depressed, or have cancer, or are not coping? Maybe a therapist who may not comprehend whole areas of experience is a fair price to pay for comfortable anonymity. The support groups are making extraordinary efforts to ensure confidentiality, but the concerns and fears remain, permanent items on the agenda.

From the community

The community informants had been randomly selected from community listings, and most of them had not had first-hand experience of using support groups, and some groups were not known to every informant. But most people interviewed in the community were aware of most of the groups’ main functions, and some had heard of others’ experiences, and some had first-hand experiences. The themes that emerged mirrored and reflected those emerging from the interviews with the people running the groups. The inspiration and dedication expressed by the coordinators is reflected in admiration and praise from the community (though this is sometimes qualified). The coordinators’ perception that people will feel more comfortable and better understood in a culture-sensitive service is reflected in the community participants views that people would and do feel more comfortable in these groups. And the coordinators’ concerns with stigma and confidentiality are reflected in the concerns and fears expressed by the community participants.

Admiration for the work done by the groups.

       (Chai) They provide good information.

(Chai) It is for cancer support. It does wonderful things.

(Ezer Leyoldos) It is marvellous. My daughter wants to put her name down to help.

(Ezer Leyoldos) I only heard about it recently. I heard that they will pay for help after the mother has given birth, and  help with babysitting, and so on. I was very impressed. I would certainly want to use them.

(Chizuk) I have heard people say that it is helpful…Builds confidence.

(Chizuk) It is a pop-in place for people with problems…a very good thing.

“Good”, “wonderful”, “marvellous”, “helpful”,  “very impressed”, “a very good thing” – these are reassuring things for the hard-working coordinators to hear. There are concerns, as we shall see, but there is a fundamental positive appreciation.

Feel safe, understood.

(Chai) Jewish people would feel more secure and more supported with other Jewish people. They have very specific problems which would not be understood by non-Jews.

(Chizuk) I believe that anyone can walk in and you cannot tell who is a volunteer and who has mental health problems. That is much better than private meetings with psychiatrists.

(Chizuk) If you have a problem you can phone them up and they will recommend the right people, the right doctors (who will understand the needs of orthodox Jewish people).

The community understands why these groups are there, and what their fundamental advantage is. But there is a “but”…

Concerns about confidentiality and stigma.

(Ezer LeYoldos) I would only consider using it if it was government funded and available for everyone…otherwise it should be reserved for those in real need.

(Ezer Leyoldos) I wonder what type of families need this? Is it just those who can’t cope? I might feel ashamed to ask for such help.

(Ezer LeYoldos) My daughter works for them, but she never discusses the families that she goes to help, as it is confidential.

(Chizuk) Do they still meet in Stamford Hill Library? I only know about them from reading advertisements, and Boruch Hashem (thank G-d) have had no need for anything like this. I would think that many people would prefer something more confidential than an open meeting.

These members of the community do indicate general admiration for the work of the groups. At the same time there is the cleft stick, the inherent conflict between the safety and understanding offered by community-led support, and the threat and fear that the client – and her family – may become known and stigmatised precisely because she is using a community-led service.

Conclusion

In this conclusion I would like to recapitulate on the emerging themes, and reflect on two issues that are latent in the material, the first to do with gender, and the second to do with spirituality. 

In describing themes, I have not picked up on every single theme that emerged from these interviews. This is largely because of my wish to try to tell a story that is not overburdened with too many intricacies and sub-plots. There were other themes, for example to do with funding and fund-raising, professionalism, and the role of the rabbinate. 

The themes that have emerged clearly at this point do relate to each other, and are reflected in the accounts of the groups’ coordinators, and in the knowledge and experiences and views of the community informants. These are the sense of  a real need for a culture-sensitive service, in which people will feel comfortable and understood. This is appreciated by the community. At the same time, there is a down-side, and this is part and parcel of providing a service in a community in which managing to be a perfect wife and mother of many children is religiously-valued and spiritually-fulfilling. Failure is stigmatising, and thus confidentiality is a huge issue. This leads to an intrinsic paradox, a contradiction which both the service providers and the community have sensed and are struggling to come to terms with. On the one hand, it is comfortable to be supported by other orthodox Jews, who can understand ones feeling and experiences, but on the other hand, one does not want the community to know about ones difficulties. All the groups have developed and are developing strategies for dealing with this issue of confidentiality. The issue has quite different dimensions from those normally seen in professional practice. Some of the solutions involve contortions which are quite clearly appropriate, but which might never appear in a standard professional code of practice manual. For example one voluntarily-staffed help line, will never try raise funds for its rental and training expenses by approaching likely donors within the community – in case these donors might have used, or might think of using the help line, and be concerned that they might be recognised. 

Finally, two latent issues. The first – gender. Even though I have lived in this community for most of my adult life, well over thirty years, and although I thought I understood the profound ways in which gender and gender-related roles are seen as routes to spiritual fulfillment, I was still startled by the minor and peripheral roles played by men in these support groups, both as providers and as users. My first “explanation” is that this was a conclusion caused by my culture-sensitive approach to doing research in this community. In this community, it would not be considered very appropriate for a woman to ask to interview a man, and in previous research I have found that gender-matching of researchers and research participants is most comfortable and yields the best results. So I recruited community participants by writing to the female head of household, mentioning in the letter however that I would be happy to interview any one adult member of the household. In the follow-up telephone call, I have suggested that I interview a male household member, where this seems appropriate, where the woman approached has not been able or willing. So far this has resulted in only one male participant. Similarly, the support groups, with only one exception, have been developed by women. The focus is often on women and their specific needs, though I have not discovered whether the majority of callers to the several help lines available, are women. In running the groups, men are called upon to play very specific roles – funding committees are often seen as men’s work, and so to is the provision of rabbinic advice and approval. These roles are seen as essential, but peripheral to the main business of providing practical and psychological support.  Where groups have been set up to provide for needs that exist among men as well as women, the men are often seen as more difficult to provide for. It may be that there is a whole other world of masculine support, but there is little trace of them. The support groups that I accessed through the community directory were generally run by women, and either focused on women’s needs, or where the needs were ungendered, men were often seen as less interested, or more difficult to provide for. 

The second latent issue is spirituality.   When I first thought about writing this chapter, I had thought about considering spiritual and religious issues that genuinely do come in therapy. I have written about some o these elsewhere (e.g. Loewenthal, 1995, 2000). But there was no sign of such issues emerging explicitly in the interviews and discussion I have had about these support groups.  But nevertheless, as I have tried to indicate in this chapter, these issues are latent. Having provided a service in which the providers and clients share religious and spiritual values, the need for these to come into explicit focus is eliminated. Having children is a spiritual activity, having faith that G-d will provide the means to support them is a fundamental belief, loving ones fellow and providing for his or her needs is a fundamental value. And one that seems to underly the provision of the groups that I have described in this chapter.

Acknowledgements

Most of the work described here was enabled by a Research Fellowship from the Leverhulme Trust. This has provided a wonderful opportunity for an aging researcher to go back to actually recruiting and doing all the interviews in a project. Thank you Leverhulme Trust. And thank you to Brooke Rogers, who undertook many of my teaching duties, as well as support work on this project, which enabled me to conduct the interviewing, analysis and writing. I would also like to thank my husband and family for their patience and support, and also my colleagues at Royal Holloway, including Rosemary Westley for her perennial willingness to provide financial and other information, advice and help. The Rabbinate of the Union of Orthodox Hebrew Congregations, particularly Dayan A.D.Dunner, have enabled the project to go ahead by offering time, advice and approval. Finally, thanks to the coordinators of the groups, and to the members of the community, who gave their time to describe their experiences of these important expressions of human goodness.