Teshuvah and the Yom Kippur cycle

1. Introduction

Version followed: Maimonides' Mishneh Torah, Hilchot Teshuvah (Laws of Repentance), chapters 1–2, for the content of teshuvah (quotations paraphrased); the annual cycle as Chabad.org's Yom Kippur glossary and the Steinsaltz Center's Concise Guide to Halakha set it out (Orthodox practice); Rav David Brofsky (Yeshivat Har Etzion) for the five afflictions; and Union for Reform Judaism guidance (ReformJudaism.org) for liberal practice on fasting. Practice differs across Orthodox, Conservative, Reform, Reconstructionist and secular Jews and between communities; ask which the client follows.

This is a religious observance, not a therapy. Teshuvah (literally "return") is, in rabbinic teaching, repentance. Maimonides describes it as abandoning the sin, regretting it, resolving in the heart not to repeat it, and confessing it in words before God (Teshuvah 1:1, 2:2–3). He holds that Yom Kippur atones for those who repent, and that it does not atone for wrongs against another person until the wrongdoer has made restitution and sought that person's forgiveness (2:9) [source: Maimonides, Hilchot Teshuvah]. The season runs from the month of Elul through Rosh Hashanah and the Ten Days of Repentance (Aseret Yemei Teshuvah) to Yom Kippur, "the climax of the High Holidays" [source: Chabad.org glossary]. Yom Kippur falls on 10 Tishri, in September or October, and is kept by fasting from food and drink and abstaining from bathing and sexual relations [source: Britannica].

In the tradition's own account, change happens through return to God and repair with other people: honest recognition, regret, a changed course and, for interpersonal wrongs, making amends. The psychotherapist does not lead or rule on any of this. The therapist's work alongside the observance is: understanding what it means in this client's life; cultural assessment; accommodation; routing health questions about fasting to the client's doctor (and halakhic questions to the client's rabbi); recognising scrupulosity and moral injury; supporting grief and community ties; and collaborating with clergy when the client wishes [synthesis].

2. Framework

The observance as the tradition publishes it

Who leads and authorises: community rabbis lead services and teach; questions of Jewish law (halakha), including whether a person may or must eat on Yom Kippur, are decided by the person's rabbi or legal decisor (posek), with medical input [source: Steinsaltz Center; IOCDF/Siev]. Liberal movements leave more to individual conscience and advise talking to a doctor before fasting [source: ReformJudaism.org].

Elul (the month before Rosh Hashanah). The shofar is blown daily in Elul except the last day; Selichot (penitential prayers) are recited [source: Chabad.org glossary]. Customs on timing differ between Ashkenazi and Sephardi communities [uncertain: not verified].
Rosh Hashanah and the Ten Days of Repentance. Aseret Yemei Teshuvah runs from Rosh Hashanah to Yom Kippur, a period for "prayer, charity and return" [source: Chabad.org glossary]. Tashlich is a related Rosh Hashanah rite [uncertain: details not verified].
Erev Yom Kippur (the day before). Customs listed by Chabad.org include kaparot (a rite with a fowl, fish or money, then given to charity), giving tzedakah, immersion in a mikvah, malkot (symbolic lashes for men), and the pre-fast meal (seudat hamafseket); memorial and "soul" candles are lit [source: Chabad.org glossary]. Because Yom Kippur does not atone for interpersonal wrongs without appeasement, people seek forgiveness from those they have wronged before the day; Maimonides says the offender should return up to three times, with three companions, after which he is released and the one who refuses is then the one at fault (2:9, paraphrased) [source: Maimonides]. Observance of each custom varies by community.
Yom Kippur. A full day of fasting, from the eve to nightfall the next day [source: Katz et al. 2009]. Five afflictions (innuyim): eating and drinking, washing, anointing, wearing leather shoes, and marital relations; eating and drinking are biblical prohibitions, and whether the other four are biblical or rabbinic is debated [source: Brofsky]. Services: Kol Nidrei opens the evening service; then morning (Shacharit), additional (Musaf, which includes the Avodah recounting the Temple service), afternoon (Minchah) and the closing Neilah; Yizkor, the memorial prayer for departed parents, is said; the Al Chet confession lists sins in alphabetical order; many wear a white kittel; the day ends with a long shofar blast (tekiah gedolah) [source: Chabad.org glossary]. Everyone is obliged to repent and confess on that day (2:7) [source: Maimonides].

Exemptions from the fast, as rabbinic authorities state them

Where fasting could endanger life, the Steinsaltz Center guide says "one should not fast", and this "applies even to pregnant and nursing women"; it advises consulting "both a doctor and a rabbi" [source: Steinsaltz Center].
After childbirth there is an initial period of full exemption and a later period of partial leniency, with rabbinic consultation [source: Steinsaltz Center].
Children below bar/bat mitzvah are not bound by Torah law; communities train them gradually by custom [source: Steinsaltz Center].
The guide describes eating and drinking in reduced, measured amounts for medically warranted cases. This is a halakhic procedure decided with the client's rabbi and doctor; the therapist does not give amounts, intervals or advice on it.
Some exemptions apply to the other afflictions (for example, washing when soiled; shoes for protection or after childbirth, in classical opinions) [source: Brofsky].
Reform guidance: children under 13 are not expected to fast; pregnant or nursing people and people who are ill are exempt; fasting should never endanger life or health; people with chronic conditions should talk to their doctor first [source: ReformJudaism.org].

The therapist's working frame (no session counts are given by any source)

No source sets a session count; work fits into ongoing therapy [synthesis].

Before the season (Av–early Elul). Goals: cultural assessment; identify health risks around the fast early enough for the client to see their doctor and rabbi; screen for scrupulosity, eating disorders, unresolved interpersonal harm and moral injury. Move on when the client has a health plan from their own doctor and rabbi (or does not fast) and you share an understanding of what the season means to them.
Elul and the Ten Days. Goals: support reflection and interpersonal repair the client chooses; watch for OCD and depressive guilt; plan for grief at Yizkor. Move on when the client has decided which repairs, if any, they will attempt and how.
Yom Kippur. No sessions on the day or the eve; agree crisis routes in advance.
After (Sukkot onward). Debrief: what the day held, unfinished repair, guilt that did not lift, grief, health problems during the fast. Return to the general treatment plan [synthesis].

3. Guiding principles

The observance is the client's, under their own authorities. Meaning: ask, do not instruct; the rabbi rules on halakha, the doctor on health, the client decides [synthesis; source: Steinsaltz Center].
Attribute religious concepts. Meaning: say "in Maimonides' teaching" or "as your community understands it", never state or dismiss atonement, divine judgement or forgiveness as fact [synthesis].
Life and health come first, as the tradition itself states. Meaning: when fasting may endanger the client, say that their own authorities exempt such cases and route them to doctor and rabbi [source: Steinsaltz Center; ReformJudaism.org].
No fasting or medicine advice from the therapist. Meaning: never suggest whether, how long or how to fast or adjust medicines; make the referral and follow up [synthesis].
Separate OCD's rules from halakha. Meaning: compulsions dressed as piety are treated; real religious obligations are respected [source: IOCDF/Siev].
Know the community norm. Meaning: compare the client's practice with how others in their community observe, with the rabbi's help, before deciding something is excessive [source: IOCDF/Siev].
Repair between people is distinct from repair with God, in the tradition's own teaching. Meaning: interpersonal amends are concrete actions toward real people, and they need safety planning [source: Maimonides 2:9; synthesis].
Forgiveness is never coerced in therapy. Meaning: Maimonides urges the wronged person to be easy to appease (2:10, paraphrased); a client harmed by abuse decides with their rabbi how this applies; the therapist does not press [synthesis].
Remorse is not pathology; persistent self-condemnation that impairs life may be. Meaning: assess guilt for function and impairment, including suicide risk [source: ISTSS; synthesis].
Grief and community are part of the day. Meaning: plan for Yizkor and for those without a community [source: Chabad.org glossary; synthesis].
Role clarity. Meaning: the therapist is not a rabbi, confessor or posek; disclose your own religious stance only when it serves the client [synthesis; spiritual competencies such as Vieten et al. 2013 [uncertain: not verified]].

4. Intervention inventory

These are the psychotherapist's own tasks alongside the observance. None is a religious rite, and none is a treatment for physical disease. Example language is illustrative throughout.

4.1 Exploring what teshuvah and the season mean to this client

Purpose / when: At the start of therapy with an observant or culturally Jewish client, and each year before Elul. The same rite can mean comfort, belonging, dread, family obligation or nothing at all [synthesis].
Steps: (1) Ask which parts of the cycle the client keeps (Selichot, Rosh Hashanah, asking forgiveness, kaparot, mikvah, Kol Nidrei, Yizkor, the fast, Neilah). (2) Ask what each means to them in their own words and which community or rabbi they follow. (3) Ask what the season has been like in past years: relief, anxiety, conflict, grief. (4) Note links to the presenting problem (guilt, a broken relationship, a bereavement, an eating disorder). (5) Record the client's own terms (teshuvah, cheshbon hanefesh, slichah) and use them back only if the client does [synthesis].
Example language (illustrative): "The High Holidays are coming up. What do they usually look like for you, and what do they stir up?" "When you say 'doing teshuvah', what does that involve for you this year?"
Watch for: Assuming observance from identity or identity from observance; your own associations with the holidays shaping the questions. It is working when the client corrects or adds to your understanding and brings the season into sessions unprompted.

4.2 Cultural Formulation Interview, with the Spirituality, Religion and Moral Traditions module

Purpose / when: Structured cultural assessment at intake or when religious material becomes clinically central. The DSM-5 supplementary Module 5 aims to clarify how spirituality, religion and moral traditions bear on the person's problems and stresses, the person's level of involvement, and its effect on coping [source: APA CFI Supplementary Modules].
Steps: (1) Use the core CFI (cultural definition of the problem, cause, coping and help-seeking) [uncertain: core domains not verified in the module document]. (2) Use Module 5's areas, paraphrased: identity and affiliation, including family background and any other traditions; the tradition's role in daily and family life; whether it helps with the problem (talking with religious leaders, texts, personal or communal practice); and whether religious matters contributed to the problem, including distress, discrimination or conflict over spiritual or moral matters [source: APA CFI Supplementary Modules]. (3) Add, where relevant, Module 3 (Social Network) for the synagogue community, Module 1 (Explanatory Model) for the client's account of guilt or suffering, and Module 10 (Older Adults) or 9 (School-Age Children and Adolescents) [source: APA CFI Supplementary Modules]. (4) Summarise back and agree how religion will (or will not) feature in the treatment plan.
Example language (illustrative): "Some people find the High Holidays a support, some find them a strain, many both. How is it for you?" "Is there a rabbi or someone in your community you talk with about this?"
Watch for: Reading Module 5 as a checklist rather than a conversation; skipping the conflict and discrimination questions. Working when the formulation names both religious resources and religious stressors.

4.3 Scheduling and treatment accommodation

Purpose / when: Before Elul each year.
Steps: (1) Check the dates of Rosh Hashanah and Yom Kippur for the year. (2) Ask which days the client cannot attend (festival days, the eve of Yom Kippur, possibly Selichot nights, Sukkot), and whether video or phone sessions are acceptable on intermediate days. (3) Avoid scheduling exposure-heavy or emotionally intense sessions just before the fast. (4) Agree a between-session plan and crisis routes (crisis line, GP, rabbi) for the days without sessions. (5) Note the end time of the fast for any post-holiday appointment [synthesis].
Example language (illustrative): "Which days over the holidays should I keep free for you, and would a phone check-in after Yom Kippur help?"
Watch for: Charging missed-session fees for religious observance without prior agreement; billing and clinic systems that do not recognise the holidays. Working when the client does not have to choose between therapy and observance.

4.4 Health planning for the fast: routing to doctor and rabbi

Purpose / when: For any client with a medical or psychiatric condition, pregnancy or recent birth, older age, or regular medicines, before the season and in good time for appointments.
Steps: (1) Ask whether the client intends to fast and whether anything in their health makes them uncertain. (2) Share what their own authorities say: that where fasting may endanger life, the Steinsaltz Center guide says one should not fast and advises consulting both a doctor and a rabbi; Reform guidance says the ill, pregnant and nursing are exempt and people with chronic illness should talk to their doctor [source: Steinsaltz Center; ReformJudaism.org]. (3) Ask the client to book an appointment with their doctor (and prescriber, for medicine questions) and to ask their rabbi. With consent, write a short note to the doctor that the client is planning for the fast. (4) Do not suggest whether to fast, how long, what to eat or drink, or any medicine change. (5) Follow up after the appointments: what was advised, how the client feels about it. (6) If the doctor and rabbi advise eating, help the client with the feelings this raises (see 4.7) [synthesis].
Example language (illustrative): "That's a question for your doctor and your rabbi together, and your tradition expects you to ask it. Could you book that this week?" "I'm not the right person to say whether you should fast, but I can help you get the answer and think through how it feels."
Watch for: The client hoping the therapist will grant permission or forbid fasting; fear of judgement delaying the appointment; dizziness, fainting, confusion or other illness during a previous fast, which the client should report to their doctor. Working when the client has a plan from their own doctor and rabbi before the eve of Yom Kippur.

4.5 Diabetes and other chronic conditions

Purpose / when: A client with diabetes (or another chronic illness) who plans to fast.
Steps: (1) Explain that physicians in Israel have published on this: a 2009 review notes that Jewish law exempts those endangered by fasting, that many people with diabetes ask their doctors, and that every diabetic patient planning to fast should consult a physician first, because some patients should not fast and those who do need close monitoring to prevent severe hypoglycaemia [source: Katz et al. 2009, abstract]. (2) Route the client to their diabetes team and rabbi; do not discuss insulin, tablets, glucose targets or break-fast thresholds. (3) Ask what the client will do if they feel unwell during the day, as advised by their doctor, and whether family or community know. (4) Afterwards, ask how it went and whether they reported any problems to their doctor [synthesis].
Example language (illustrative): "Doctors who work with Jewish patients say people with diabetes should see their physician before deciding about the fast. Have you had that conversation this year?"
Watch for: Shame about being unable to fast; a client keeping a medical problem from the rabbi or the doctor from the rabbi. Working when the client's decision is made with their medical team.

4.6 Eating disorders and the fast

Purpose / when: A client with a current or past eating disorder, or with restriction disguised as piety.
Steps: (1) Ask directly how the fast interacts with their eating difficulties. (2) Involve the eating-disorder team and medical doctor; the decision on fasting belongs to the doctor and rabbi with the client. (3) Offer the alternatives liberal institutions publish (4.7). (4) Plan for pre-fast and break-fast meals and family dynamics with the treating team [source: ReformJudaism.org, which presents a personal account of fasting harming recovery; synthesis].
Example language (illustrative): "For some people in recovery the fast becomes the eating disorder's permission slip. Is that a risk for you?"
Watch for: Extending restriction before or after the day; compensatory behaviour at the break-fast. Working when the client experiences the decision as protecting both recovery and religious life.

4.7 Meaningful participation when exempt

Purpose / when: A client who has been advised not to fast, or to eat in measured amounts, and feels excluded or guilty.
Steps: (1) Validate the loss. (2) Explore what the client's tradition offers. Reform guidance suggests a meditation for those who cannot fast by Rabbi Simkha Y. Weintraub, giving the money saved to a hunger charity such as Mazon, volunteering or food drives [source: ReformJudaism.org]. (3) For Orthodox clients, ask their rabbi how they should understand eating on the day; the therapist does not supply the halakhic framing [synthesis]. (4) Help the client choose other parts of the day (prayer, Yizkor, confession, interpersonal repair) to invest in.
Example language (illustrative): "Your rabbi and doctor said not to fast. What would help this still feel like Yom Kippur for you?"
Watch for: The client fasting in secret against advice; shame in the synagogue. Working when the client describes the day as theirs despite eating.

4.8 Screening for scrupulosity in the season

Purpose / when: Each year before Elul with clients who have OCD, perfectionism or excessive guilt, and whenever religious practice looks driven by fear.
Steps: (1) Ask about time spent on religious checking, repeating, confessing or asking rabbinic questions (shaylas). (2) Look for the domains the IOCDF lists for Jewish scrupulosity: prayer articulation and concentration (kavanah), vows and fear of inadvertent commitments, kashrut, purity, Sabbath, sexual thoughts, blasphemy, and over-asking shaylas [source: IOCDF/Siev]. (3) In this season, ask also about repeated or ever-lengthening confession, inability to stop listing sins, re-asking people for forgiveness after they have granted it, fear that one's teshuvah "didn't count", and dread of divine judgement that blocks sleep or work [synthesis: extrapolated from the IOCDF domains, which do not discuss Yom Kippur]. (4) Apply the IOCDF's three distinctions: community norms, motivation (anxiety reduction means compulsion), and functional impairment [source: IOCDF/Siev]. (5) If positive, assess formally for OCD.
Example language (illustrative): "When you confess or ask forgiveness, do you feel done afterwards, or does a voice say 'not enough, again'?"
Watch for: Mistaking strict but normal observance for OCD, or OCD for piety. Working when you and the client can name which behaviours are religion and which are the OCD.

4.9 ERP for scrupulosity, adapted with the client's rabbi

Purpose / when: Diagnosed OCD with religious content that flares around confession, forgiveness, prayer or the fast. ERP is first-line; for scrupulosity it aims to remove OCD's influence from religious life without asking the client to choose between values and health; the task is to break OCD's rules without breaking halakha, which first requires telling the two apart [source: IOCDF/Siev]. Huppert, Siev and Kushner describe adapting ERP to fit ultra-Orthodox patients' beliefs to improve motivation and engagement [source: Huppert et al. 2007, abstract].
Consent and safety: Explain ERP, its temporary rise in anxiety and the client's right to stop; obtain written consent for contacting the rabbi; exclude any exposure that would break halakha as the client's rabbi defines it, and any exposure involving fasting, sleep loss or health risk; pace hierarchies around the holidays (avoid starting hard steps just before the fast); check suicide risk and depression before starting [synthesis].
Steps: (1) With consent, consult the client's rabbi or posek to establish what the law actually requires (for example, whether the set liturgy of confession is sufficient, whether one request for forgiveness suffices once granted, what standard of kavanah is expected) [source: IOCDF/Siev for consulting a posek; specific questions are synthesis]. (2) Ask the rabbi, if willing, to give one clear ruling the client can rely on rather than answering repeated questions; the IOCDF lists over-asking shaylas as a symptom, and Jewish law has principles against endless doubt, such as not hedging against very unlikely doubts and "perfection is not the legal standard" [source: IOCDF/Siev]. (3) Build a hierarchy of OCD rules (not halakhic duties) to break: for example, saying the Al Chet once with the congregation without repeating lines; asking a person's forgiveness once and accepting the answer; not re-asking the rabbi; not reviewing the day for missed sins; tolerating the thought "maybe my teshuvah didn't count" [synthesis]. (4) Run exposures in session and as homework with response prevention, rating distress. (5) Review with the client, and the rabbi if agreed, after the holidays.
Example language (illustrative): "Your rabbi said the words of the service are enough. The OCD says they aren't. This week we practise siding with your rabbi." "The aim isn't to make you less religious. It's to get the OCD out of your davening."
Watch for: The therapist designing an exposure that breaches the client's law (refer back to the rabbi); the rabbi's reassurance becoming a new compulsion; rabbinic consultation being sought for every step. Working when religious practice takes the time and form the community norm suggests and the client reports more meaning, not just less anxiety.

4.10 Preparing to seek forgiveness from someone wronged

Purpose / when: A client who, in the season, wants to make amends with a real person. Maimonides teaches that Yom Kippur does not atone for interpersonal wrongs until restitution is made and the injured person is appeased (2:9); public confession of wrongs against others is praiseworthy (2:5) [source: Maimonides].
Steps: (1) Clarify what the client did and what they owe in their own view, and what their rabbi advises. (2) Assess safety and harm: would contact retraumatise the other person, breach a no-contact order or reopen an abusive relationship? If so, explore alternatives with the client's rabbi. (3) Distinguish apology from restitution (paying back, correcting a record). (4) Rehearse a specific, unhedged apology and prepare for refusal. (5) Note Maimonides' limit: after returning up to three times with companions, the offender is released (2:9); a client with scrupulosity may use this as a defined stopping point agreed with their rabbi [source: Maimonides; stopping-point use is synthesis]. (6) Debrief.
Example language (illustrative): "What would a real apology to your brother include, and what are you afraid he'll say?" "If he says no, what does your tradition, and your rabbi, say happens then?"
Watch for: Apologies used to extract forgiveness or reassurance; amends that place the other person at risk. Working when the client acts and can tolerate the outcome.

4.11 When the client is asked to forgive, especially after abuse

Purpose / when: A client approached for forgiveness by someone who harmed them, or who feels religious pressure to forgive. Maimonides urges the wronged person not to be cruel, to be easy to appease and slow to anger, and to forgive wholeheartedly (2:10, paraphrased) [source: Maimonides].
Steps: (1) Hear the client's religious understanding without correcting it. (2) Separate forgiving, reconciling and resuming contact; they are different decisions [synthesis]. (3) Assess safety and any current abuse; follow safeguarding duties where children or vulnerable adults are at risk. (4) Encourage the client, if they wish, to ask their own rabbi how these teachings apply to abuse; the therapist does not issue a religious ruling either way [synthesis]. (5) Support whatever decision the client reaches.
Example language (illustrative): "You can take your rabbi's guidance on what forgiveness asks of you. Whether you see him, and whether you're safe, we can think through here."
Watch for: Family or community pressure framed as religious duty; the offender using the season to regain access. Working when the client's decision is their own and safe.

4.12 Moral injury alongside teshuvah

Purpose / when: A client who perpetrated, failed to prevent or witnessed acts that "transgress deeply held moral beliefs and expectations" (veterans, health workers, first responders, a driver who killed a pedestrian), for whom the season brings guilt, shame, self-condemnation and withdrawal [source: Litz et al. 2009; ISTSS fact sheet].
Steps (following Litz et al.'s preliminary model, adapted): (1) Connection: build safety to disclose without condemnation. (2) Preparation: explain moral injury and how concealment and avoidance keep it going. (3) Modified exposure: revisit the event to bring the self-condemning beliefs into view (emotional engagement, not fear extinction). (4) Examination: balance attributions and separate the person's worth from one act. (5) Imaginal dialogue with a benevolent moral authority; Litz et al. note a religious or spiritual figure can serve, so a client may choose a rabbi, a teacher or a figure from their tradition. (6) Reparation and forgiveness: realistic, concrete actions that reconnect with values; the authors caution against trying to right the past. (7) Reconnection with family and community. (8) Planning for when the injury resurfaces [source: Litz et al. 2009]. (9) With consent, link the client with a rabbi or chaplain for the religious side of confession and atonement; the ISTSS sheet names chaplains as able to assess and support [source: ISTSS; synthesis].
Example language (illustrative): "Yom Kippur asks you to look at what you did. In here we can look at it too, at a pace you can bear." "If someone you trust in your tradition heard the whole story, what would they say to you?"
Watch for: Exposure without the client's consent or before stabilisation; punitive images of God, which Litz et al. link to worse outcomes; suicide risk (see 4.13). Working when shame lessens enough for the client to reconnect and act on values.

4.13 Guilt, self-condemnation and risk

Purpose / when: Guilt that does not lift after the day, or that grows through the season.
Steps: (1) Ask what the client's tradition says about whether repentance is accepted; Maimonides holds that teshuvah atones for every sin (1:3, paraphrased) and that even late repentance counts (2:1) [source: Maimonides]; let the client or their rabbi draw the application. (2) Assess depression, OCD and PTSD. (3) Ask directly about suicidal thoughts and belief that one deserves punishment; the ISTSS sheet notes some people with moral injury are at risk of suicide [source: ISTSS]. (4) Follow current local risk-assessment practice and safety planning [synthesis].
Example language (illustrative): "Sometimes the day leaves people feeling they don't deserve to go on. Has anything like that crossed your mind?"
Watch for: Guilt about a trivial or imagined act (OCD or depression); absolute statements of unforgivability. Working when guilt becomes proportionate and linked to action.

4.14 Grief, Yizkor and memorial candles

Purpose / when: Bereaved clients. Yizkor, the memorial prayer for departed parents, is said on Yom Kippur, and memorial candles are lit [source: Chabad.org glossary].
Steps: (1) Before the holidays, ask whether Yizkor or the candle will be the first since a death. (2) Plan support for the day (who will sit with them; some communities have customs about who stays in for Yizkor [uncertain: not verified]). (3) Explore unresolved conflict with the deceased, which teshuvah themes can stir. (4) Debrief afterwards.
Example language (illustrative): "This will be your first Yizkor since your mother died. How do you want to get through that part of the day?"
Watch for: Complicated grief; guilt toward the dead. Working when the ritual holds the grief rather than overwhelming the client.

4.15 Community, estrangement and religious trauma

Purpose / when: Clients who have left observance, been excluded, are LGBTQ+ in an unaccepting community, or who carry religious trauma; the season can bring loneliness, family pressure or flashbacks [synthesis].
Steps: (1) Ask how the client wants to spend the days (with family, a different congregation, alone, not at all). (2) Validate both longing and aversion. (3) Help locate a community that fits, if they want one. (4) Plan for family encounters (boundaries, exits). (5) Treat trauma symptoms by usual evidence-based methods [synthesis].
Example language (illustrative): "You don't have to decide what you believe to decide where you'll be on Yom Kippur."
Watch for: The therapist steering toward or away from religion. Working when the client's choice reduces distress.

4.16 Collaboration with rabbis and chaplains

Purpose / when: Halakhic questions (fasting exemptions, scrupulosity rulings), religious aspects of moral injury, or community support, when the client wishes.
Steps: (1) Obtain written, specific consent: what will be shared and why. (2) Agree roles: the rabbi rules on law and guides religious life; the doctor on health; the therapist on psychological treatment. (3) Prepare focused questions (see 4.9). (4) Share only what is needed. (5) Feed back to the client and record the outcome [source: Steinsaltz Center and IOCDF/Siev for consulting rabbi and doctor; procedure is synthesis].
Example language (illustrative): "Would it help if I spoke with your rabbi about what's halakha and what's the OCD? You'd choose what I can say."
Watch for: Rabbi and doctor disagreeing (see 5); a rabbi unfamiliar with OCD; confidentiality in a small community. Working when the client receives one consistent message.

4.17 Children and adolescents

Purpose / when: Young clients and families. Children below bar/bat mitzvah are not bound by Torah law; communities train them by custom from a young age [source: Steinsaltz Center]; Reform guidance does not expect under-13s to fast [source: ReformJudaism.org].
Steps: (1) Ask the young person and parents separately what is expected. (2) Route medical questions (diabetes, eating disorders, growth) to the paediatrician. (3) Seek the young person's assent as well as parental consent for anything involving the rabbi. (4) Follow safeguarding procedures if fasting or ritual is imposed harmfully [synthesis].
Example language (illustrative): "What does your family expect of you on Yom Kippur this year, and how do you feel about it?"
Watch for: An adolescent with an eating disorder using the fast; scrupulosity emerging around bar/bat mitzvah. Working when expectations are clear and safe.

4.18 Role boundaries and self-disclosure

Purpose / when: Throughout, especially with clients who see the therapist as a confessor or ask about the therapist's own observance.
Steps: (1) Do not hear confession as a religious act, rule on law or grant forgiveness on God's behalf. (2) Avoid dual relationships, such as treating members of your own congregation, where possible; if unavoidable, discuss boundaries. (3) Disclose your own religious stance only when it serves the client, briefly. (4) Seek supervision when your own beliefs or holiday feelings are stirred. Follow your profession's ethics code [synthesis].
Example language (illustrative): "I can hear what's weighing on you. Forgiveness in the religious sense is something to take to your rabbi and your prayers; in here we can work on what keeps you stuck."
Watch for: Clients seeking absolution from the therapist; therapist countertransference. Working when the client uses both therapist and clergy for their distinct roles.

4.19 After Yom Kippur: debrief

Purpose / when: First session after the holidays.
Steps: (1) Ask what the day held: prayer, fast, Yizkor, Neilah, the closing shofar. (2) Review health during the fast and whether problems were reported to the doctor. (3) Review interpersonal repairs attempted. (4) Check guilt and OCD symptoms. (5) Note learning for next year's planning [synthesis].
Example language (illustrative): "How was the day, and how are you now that it's over?"
Watch for: Post-holiday low mood or a sense of failure. Working when the client takes something usable from the season.

5. Handling problems

Sources address few of these directly; responses are synthesis unless tagged.

The client asks the therapist whether they may eat on Yom Kippur. Decline the ruling, not the person. Name the tradition's own route: doctor and rabbi together [source: Steinsaltz Center]. Help book the appointments and rehearse the questions. "I'd be guessing at both medicine and halakha. Let's get you to the people your tradition says should answer." (illustrative)
Doctor advises not fasting; client or rabbi disagrees, or the reverse. Do not adjudicate. With consent, suggest the client asks doctor and rabbi to speak to each other, or brings the doctor's written advice to the rabbi. If the client chooses to fast against medical advice, respect autonomy, make sure their doctor knows, and ask what the doctor said to do if they feel ill. Assess capacity and risk only if there are psychiatric grounds [synthesis].
Repeated shaylas and reassurance seeking (from rabbi, family or therapist). Treat as a compulsion [source: IOCDF/Siev]. Agree with the rabbi on one ruling to rely on; stop answering reassurance questions in session, explaining why.
Endless confession or re-apologising. Use the set liturgy or Maimonides' three-approach limit (2:9) as an agreed boundary, confirmed by the rabbi, and build ERP steps around it (4.9, 4.10) [source: Maimonides; synthesis].
Client fears the therapist will undermine their faith. Restate that the goal is to remove the OCD's or depression's hold on religious life, not religion itself [source: IOCDF/Siev]. Offer rabbinic consultation.
Client wants the therapist to be their confessor or source of absolution. Reflect the wish; return religious forgiveness to the client's tradition and clergy; work on what blocks self-acceptance (4.18).
Stuck in self-condemnation after the holidays. Assess depression, OCD, PTSD and suicide risk (4.13); consider moral injury work (4.12); involve a chaplain or rabbi if the client wishes [source: Litz et al. 2009; ISTSS].
Overwhelm during long services or the fast (panic, dissociation, intrusive memories). Before the day, agree grounding the client can use in a pew (noticing feet, the text, the room), a place to step out, and a person to sit with. Faintness or physical illness goes to medical care, not grounding [synthesis].
Non-adherence to plans (the client skips the doctor's appointment, or abandons ERP homework in the season). Explore what got in the way (shame, time, fear of a ruling). Shrink the step. Accept a pause in ERP over the holidays if the client wishes, with a restart date.
Pressure to forgive or reconcile with an abuser. Prioritise safety and safeguarding; separate forgiveness from contact; refer the religious question to a rabbi the client trusts (4.11).
Kaparot, malkot or mikvah become compulsive or distressing. Explore meaning and function; consult the rabbi on what is required; treat compulsive versions as OCD [synthesis].
Rupture: therapist forgets the holiday, schedules over it, or makes a misinformed comment. Acknowledge directly, repair the schedule, invite correction. "I got that wrong, and it matters. Tell me how it actually works in your community." (illustrative)
Therapist of a different (or the same) background. Ask rather than assume; for same-background therapists, guard against importing your own community's norms or rulings [synthesis].
Spiritual distress as the focus of care. DSM-5-TR includes a code for a religious or spiritual problem, Z65.8 [source: ICD-10-CM Z65.8]; use it where the distress itself is the clinical focus and no disorder better explains it, without pathologising normal penitential sorrow [synthesis].
Client has no community and spends Yom Kippur alone. Help them choose: a congregation, an online service, a personal ritual, or a deliberate non-observance; plan a contact for the evening [synthesis].

Sources

Online sources:

Also cited: Vieten et al. 2013 on spiritual and religious competencies [uncertain: not verified].

ICD-10-CM Z65.8, Other specified problems related to psychosocial circumstances (includes 'Religious or spiritual problem'), https://www.unboundmedicine.com/icd/view/ICD-10-CM/945432/all/Z65_8___Other_specified_problems_related_to_psychosocial_circumstances

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