Israel journal of psychiatry and related sciences

israel journal of

psychiatry

Ma n a gi n g s u b o p t i m a l res p o ns e to antid ep res s ant therapy

Seroquel XR ‫הוספת‬

50% -‫הוכחה כמשפרת בכ‬

‫את סיכויי ההגעה‬ ‫לרמיסייה בדיכאון‬

Culture and Psychiatry

Vol. 49 - Number 3 2012

ISSN: 0333-7308

151 Psychiatric services and Ethiopians in Israel

2

‫בהשוואה לטיפול בנוגד דיכאון בלבד‬

Rafael Youngmann et al.

159 Volume 49, Number 3, 2012 Israel Journal of Psychiatry and Related Sciences

-on

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‫חדש‬ Seroquel XR is indicated for add-on treatment of major depressive episodes in patients with major depressive disorder (MDD) who have had suboptimal response to antidepressant monotherapy.1 The recommended daily dose is 150mg, however if clinically justified the dose may be increase to 300mg.

Seroquel XR is also indicated for schizophrenia and bipolar.1

08-13-SER-12-IL-030

References: 1. Seroquel XR MoH Approved Prescribing Information 2. Bauer et al. Journal of Affective Disorders 2010; 127:19–30

09-7406528 :‫ טלפון‬,43656 ‫ רעננה‬4070 .‫ד‬.‫ת‬ Israel.infoisrael@astrazeneca.com 09-7406529 :‫פקס‬ Seroquel XR® is a registered trademark of AstraZeneca group of companies.

The AstraZeneca logo is a trademark of AstraZeneca group of companies

Mental health of Jews in the U.K. Kate Miriam Loewenthal

167 Community study of Bedouin servicemen Yael Caspi and Ehud Klein

178 Female circumcision RH Belmaker

184 Attachment patterns of Arabs and Jews Shiri Lavy et al.

194 Sociocultural information at intake Margarita Alegria et al.

202 Social identities and mental health disparities Ora Nakash et al.

MDD (Add-on)

150mg

‫עכשיו מאושרת בישראל‬ 1 ‫כתוספת לטיפול בדיכאון‬ ‫חדש‬ ‫זמינה כטיפול לדיכאון בביטוח‬ ‫המשלים של חלק מקופות החולים‬

211 Palestinian families and War in Israel Khawla Abu-Baker

219 A women's counselling service in the Negev Julie Cwikel and Andrea Ifergane

227 Cultural competence training Julia Mirsky

‫זיפרקסה המקורית‬

‫זיפרקסה בשחרור ממושך‬

ZY071210 ‫למידע מלא אנא עיין בעלון לרופא כפי שאושר ע”י משרד הבריאות‬

is indicated for the short-term treatment of acute manic episodes associated with Bipolar I Disorder

ZypAdhera :‫שם התכשיר‬ olanzapine pamoate :‫חומר פעיל‬ 210mg, 300 mg, 405 mg prolonged release Injection :‫מינונים‬ ZYPADHERA is indicated for the treatment of schizophrenia :‫התוויות מאושרות‬ Lilly Pharma, Giessen, Germany :‫יצרן‬ ‫ אלי לילי ישראל בע"מ‬:‫יבואן‬

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‫לטיפול בדכאון‬ 1 ‫עוצמה כפולה כבר מההתחלה‬

‫מהיר יותר‬ ‫ מצב רוח וכאב‬,‫הקלה בתסמיני חרדה‬ 2 ‫מהשבוע הראשון‬ 7 ‫שיפור במדדי התפקוד‬

‫בטוח יותר‬ ‫בקשישים ובחולים עם גורמי סיכון‬ 5,6 ‫קרדיווסקולרים‬

‫פשוט ונוח יותר‬ ‫ מג' כבר מהיום הראשון‬60 ‫קפסולה אחת של‬ '‫ מג‬60-120 ‫מינון יומי מומלץ‬

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‫מוכח יותר‬ ‫בהקלה על התסמינים הנפשיים והתסמינים‬ 3 ‫הכואבים הנלווים לדכאון‬

2008 ‫ נכלל בסל הבריאות‬,‫ אלי לילי ישראל בע"מ‬:‫ יבואן‬,‫ לילי בע"מ ספרד‬:‫ יצרן‬Duloxetine as hydrochloride '‫ מג‬60 -‫ מג' ו‬30 ‫ כמוסות של‬:‫ מינונים‬,Duloxetine as HCL :‫ חומר פעיל‬,Cymbalta :‫שם התכשיר‬ ‫ למידע מלא נא עיין בעלון מידע לרופא כפי שאושר ע"י משרד הבריאות‬.‫לטיפול בכאב נוירופתי‬ :‫התוויה מאושרת‬

 Cymbalta is indicated for the treatment of major depressive episodes.  Cymbalta is indicated for the management of neuropathic pain associated with diabetic peripheral neuropathy (DNP).  Cymbalta is indicated for the treatment of generalized anxiety disorder (GAD)  Cymbalta is indicated for the management of fibromyalgia (FM).  Cymbalta is indicated for the management of chronic musculoskeletal pain when other therapies have failed or are contra-indicated.

References: 1. Bymaster et al, Current Pharmaceutical Design, 2005. 11:1475-1493; 2. Brannan et al. J Psych Res 2005; 39: 161-172; 3. Brecht S, et al. J Clin Psychiatry. 68:1707- 1716. 2007; 4. Cymbalta PI; 5. Raskin J et al, Am J Psychiatry 2007; 164:900–909; 6. Wernicke J, et al. Drug Safety 2007;30 (5):437-455; 7. Wohlreich MM, et al. J Clin Psychopharmacol 2005; 25: 552-560 CY061126

!‫חדש‬

,‫סירקדין‬ ‫ה‬ ‫ת‬ ‫ר‬ ‫ו‬ ‫פ‬ ‫ה‬ ‫המאושרת ל היחידה‬ ‫ל‬ ‫ה‬ ‫פ‬ ‫ר‬ ‫ע‬ ‫ו‬ ‫שימוש לפרק ז ת שינה‬ ‫עד‬ ‫מן של‬

3 1 ‫ש‬ ‫ב‬ ‫ו‬ * ‫עות‬

,‫סירקדין‬ !‫לישון כמו שצריך‬ :‫סירקדין מספק למטופלים שלך בדיוק מה שהם צריכים‬ .‫ לשחזור מבנה השינה התקין במהלך כל שעות הלילה‬,‫מלטונין בשחרור מושהה‬ :‫סירקדין מכוון לענות על צרכי המטופלים שלך‬ ‫הירדמות קלה ומהירה‬ ‫שינה רצופה ומרעננת‬ ‫שיפור משמעותי באיכות החיים‬ ,‫כשאתה רושם לו סירקדין‬ !‫אתה מאפשר לו לישון כמו שצריך‬ .‫ שבועות בלבד‬4 ‫ מאושרות לשימוש עד‬, ‫) להן אינדיקציה לטיפול בנדודי שינה בישראל‬Z-‫* כל התרופות ההיפנוטיות (בנזודיאזפינים ותרופות ה‬ References: 1). Fourtillan J. B. Role of melatonin in the induction and maintenance of sleep. Dialogues Clin Neurosci 2002;4:395-401. 2). Wade A. G. et al. Efficacy of prolonged release melatonin in insomnia patients aged 55–80 years: quality of sleep and next-day alertness outcomes. Curr Med Res Opin 2007;23(10):2597-2605. 3). Otmani S. et al. Effects of prolonged-release melatonin, zolpidem, and their combination on psychomotor functions, memory recall, and driving skills in healthy middle aged and elderly volunteers. Hum Psychopharmacol Clin Exp 2008; Published online in Wiley InterScience. 4). Luthinger R. et al. The effect of prolonged release Melatonin on sleep measures and psychomotor performance in elderly patients with insomnia. Int Clin Psychopharmacol 2009. 5). Paul M. A. et al. Sleep-Inducing Pharmaceuticals: A Comparison of Melatonin, Zaleplon, Zopiclone, and Temazepam. Aviation Space Environmental Med 2004;75(6):512-519. 6). Lemoine P. et al. Prolonged release melatonin improves sleep quality and morning alertness in insomnia patients aged 55 years and older and has no withdrawal effects. J Sleep Res 2007;16:372-380.

146

israel journal of

psychiatry and related sciences EDitor

David Greenberg DEPUTY EDITORS

David Roe Rael Strous Gil Zalsman

Book reviews editor

Yoram Barak PAst Editor

Eli L. Edelstein Founding Editor

Heinz Z. Winnik Editorial Board

Alean Al-Krenawi Alan Apter Omer Bonne Elliot Gershon Talma Hendler Ehud Klein Ilana Kremer ltzhak Levav Yuval Melamed Shlomo Mendlovic Ronnen Segman Eliezer Witztum Zvi Zemishlany International Advisory Board

Yoram Bilu Aaron Bodenheimer Carl Eisdorfer Julian Leff Margarete Mitscherlich-Nielsen Peter Neubauer Phyllis Palgi Leo Rangell Melvin Sabshin Robert Wallerstein Myrna Weissman

Culture and psychiatry 148 > Editorial: Culture and Psychiatry Ora Nakash and Itzhak Levav

Community and psychopathology

151 > Utilization Patterns of

Ambulatory Psychiatric Services by Ethiopian Immigrants in Israel Rafael Youngmann, Ina Pugachova and Nelly Zilber

Marketing: MediaFarm Group

+972-77-3219970 23 Zamenhoff st.

Tel-Aviv 64373, Israel

amir@mediafarm.co.il www.mediafarm.co.il

Vol. 49 - Number 3 2012

202 > The Effect of Social Identities of Service-Users and Clinicians on Mental Health Disparities: A Review of Theory and Facts

Ora Nakash, Tamar Saguy and Itzhak Levav

211 > Psycho-Social Reactions of

Palestinian Families in Israel and the West Bank Following War-related Losses

Khawla Abu-Baker

159 > Mental Health and Mental Health Care for Jews in the Diaspora, with Particular Reference to the U.K.

219 > Three Years of Isha Be-Shela, A

Kate Miriam Loewenthal

Julie Cwikel and Andrea Ifergane

167 > In the Aftermath of Trauma: A Community Study of Bedouin IDF Servicemen and Their Families

227 > In Praise of CulturalCompetence Training for Mental Health Professionals

Yael Caspi and Ehud Klein

Julia Mirsky

178 > Successful Cultural Change:

235 > Book reviews

The Example of Female Circumcision among Israeli Bedouins and Israeli Jews from Ethiopia

Women’s Counseling Center in the Negev – a Mixed Method Analysis

RH Belmaker

184 > Attachment Patterns of Arabs and Jews in Israel - Are We Really So Different?

Shiri Lavy, Faisal Azaiza and Mario Mikulincer Culture and clinical practice

194 > The Role of Sociocultural

Information in Mental Health Intake Sessions

Margarita Alegría, Arlene Katz, Rachel Zack Ishikawa, Yaminette Diaz-Linhart, Anne Valentine and Sheri Lapatin

Hebrew Section

237 > News and Notes 241 > Abstracts

Assistant Editor

Joan Hooper

The Official Publication of the Israel Psychiatric Association

View from Aminadav Emi Shufman acrylic on canvas

Emi Shufman is a psychiatrist: "I have been painting for 32 years, usually in the mountains of Jerusalem or the coastline of Jaffa. I am unable to paint indoors. My inspiration is through all five senses in nature, my style a naive surrealism."

Isr J Psychiatry Relat Sci - Vol. 49 - No 3 (2012)

Editorial: Culture and Psychiatry Both the impact of globalization as well as the local struggles for a melting pot society do not erase the cultural distinctiveness of the multiple population groups in Israel. Like no other Western country, Israeli society is a mosaic of cultural identities (1). For more than 60 years since its establishment, Israel has been absorbing immigrants, mainly Jewish, from all over the world. As a result, Israeli Jews, 75% of the country’s total population, are ethnically diverse. Approximately 9% of them are immigrants from North Africa and Asia, 8% came from Europe and America, and 12% from the former Soviet Union. The latest immigrants to arrive came from Ethiopia (currently constitute approximately 1.3% of the Jewish population) (2). In addition, 18% of the Jewish population comprises second-generation Israeli Jews whose fathers were born in North Africa or Asia and 15% in Europe or America. Lastly, the third-generation Israeli Jews total 37% of the Jewish population (2). A substantial minority, 25%, of the population is non-Jewish, including Moslem, Christian, Druze and Bedouin groups, each holding their own unique beliefs and health-related practices (1, 2). It is thus obvious that such a varied human mosaic precludes a “culture-blind� mental health practice. the definition of culture in mental health is challenging (3). Recent consensus speaks of a socially-transmitted constellation or construction which includes beliefs, attitudes, practices, ideas, values, institutions, and physical environments (3). Cultural values, e.g., expectations about context, age and gender normative behaviors and family dynamics, as well as beliefs about health and health care (4), have the potential to positively and negatively affect the mental health status and practices of members of a group, as well as to set the course and outcome of the clinical encounter when this takes place.

The social and cultural contexts (gender, social class, educational level, poverty, and age role expectations, among other factors) provide meaning to what people, as well as the self, regard as being normal or abnormal. As an illustration, education is tied to modes of clinical presentation and symptom severity assessment (5), religion and spirituality may be linked to the experience of illness (6), and gender and sexual orientation are intimately connected to expectations about societal roles and may be relevant in risk assessment (7, 8).

148

In sum, culture is associated with the determinants of mental and behavioral disorders, it gives birth to mental health beliefs, modulates the expression of psychological distress and draws the path for help-seeking practices. For the clinic, the preceding factors are crucial for refining the identification and care of mental health distress and conditions for members of culturally diverse groups.

This special issue of The Israel Journal of Psychiatry is dedicated to aspects arising from the interplay between culture and psychiatry, and includes articles covering selected subjects of contemporary clinical interest. The first part refers to those situated at the intersection between the culture of certain population groups and mental health.

Youngmann, Pugachova and Zilber compared mental health service utilization patterns among immigrants from Ethiopia and the former Soviet Union and local-born Jewish Israelis. Their findings document differences in referral sources and treatment recommendations, thus highlighting the need to develop culturally-sensitive intervention programs. In the following article, Loewenthal expands the discussion of local cultural groups and reviews a series of studies on mental health status and care for Jews in the Diaspora, with particular focus on the United Kingdom.

Caspi and Klein report the effect of trauma and posttraumatic stress disorder on Bedouin Army servicemen and their family members, and document high mental health needs but low service utilization. Belmaker presents interesting longitudinal data on the practice of female circumcision among Bedouins and Jews from Ethiopia. Based on a series of studies he documents changes in traditional practices that clash with modern tenets in gender-related issues and health prescriptions. Lavy, Azaiza and Mikulincer close this section with data on attachment orientations of Arabs and Jews that account for higher attachment anxiety among the former.

Culture is an integral part of the clinical encounter.

The second part of this special issue is dedicated to articles discussing subjects arising from the intersection between culture and psychiatry before and during the clinical encounter.

Topics that emerge prior to the clinical encoun-

Ora Nakash and Itzhak Levav.

ter refer to health disparities, defined as populationspecific differences in the onset, prevalence, severity of disorder, and differential access to health care. The populations most seriously affected by adverse health disparities include ethnic minorities that often seek and receive care partially or fully affected by language and cultural barriers. The research to date on disparities in Israel has focused on health-related outcomes, with important differences found in life expectancy and illness rates as a result of cultural background, immigration history, socioeconomic status, gender, and residence area (1, 2, 9). As well, relatively recent epidemiological studies show that prevalence rates of mental health disorders are higher among Arab Israelis compared with Jewish Israelis (10), and between recent immigrants from the former Soviet Union and native Israelis (11). Consistent differences in mental health also exist between Mizrahim (primarily Jews of Asian/ North African descent) and Ashkenazim (primarily Jews of European/American descent); Mizrahim are twice as likely to suffer from mood or anxiety disorders compared to Ashkenazim (12).

In many urban mental health clinics worldwide clinicians encounter a growing multicultural population.

In Israel, this population includes service users with limited Hebrew proficiency, and views of mental disorders and values different from those of the caregiver.

Clinicians are charged with providing culturally sensitive care (13). However, doing so is difficult, because complex information is needed to understand and be empathic to patients from a different culture (4, 14, 15).

The U.S. Surgeon General’s Report on Culture, Race and Ethnicity argues that a person’s culture may impact what s/he reports, what the clinician prompts the patient to report, and how the clinician interprets the information provided (16). Culture is the backdrop for the interpersonal dimension of the clinical encounter and informs the overall conceptualization of diagnostic symptoms and treatment recommendations. Culture affects psychopathology, with clinical implications that include over- or under-pathologizing of minorities (17).

Alegría, Katz, Ishikawa, et al., in the opening article of the second section, provide U.S.-based data on mechanisms contributing to the mental health disparities focusing on the way clinicians use socio-cultural information during the mental health intake. Their findings suggest that socio-cultural information is critical to engaging patients and being able to be empathic to their needs particularly with minority patients. Nakash,

Saguy and Levav propose a conceptual model to assist in identifying mechanisms contributing to the mental health disparities in the clinic. The model is based on social psychological research, with particular emphasis on processes rooted in social categorization and social power. The authors suggest that the contrasting social identities of clinicians and service users can partially account for why discordant, compared to concordant ethnic identities in clinical encounters may produce worse clinical outcomes. Abu-Baker compared the psychosocial reactions to personal losses of Palestinian families in the West Bank and in Israel. Her analyses of the themes that emerged during the clinical interventions with women of both groups highlight the complex relationship between the social and political environment created by the protracted Israeli-Palestinian conflict and the personal selves in the working through of their trauma and loss.

Although most therapies in urban mental health clinics tend to be cross-cultural, clinicians vary in the extent and the way in which they address cultural differences in the clinical encounter (18). Mental health clinicians are rarely trained in areas such as: communicating essential concepts and information for effective mental healthcare in different languages; working effectively with patients who have limited health literacy; or effectively adapting services for diverse populations.

Clinical training programs and psychiatric practice in general bring limited tools for addressing ethnocentric biases among clinicians in their practice. Not attending to this bias has resulted in cultural misunderstandings with negative effects on clinical services and financial burden. Kirmayer, et al. (19) described misunderstandings resulting in incomplete assessments, incorrect diagnoses, inadequate or inappropriate treatment, and failed treatment alliances in inpatient services. A counterargument in research has looked at a more universalistic, non-culture-specific approach as being a simpler way to assess and classify psychiatric disorders based on agreed upon symptoms (20), thereby reducing the risk of clinical and scientific confusion (21, 22). However, cross-cultural validity of diagnosis can be enhanced when indigenous categories of experience are incorporated into assessment and “normative uncertainty,” distinguishing between psychiatric disorders and culturally determined responses to illness (23).

The last two papers capture some of those issues through concrete examples of culturally-competent care and training. Cwikel and Ifergane describe the services 149

Editorial: Culture and Psychiatry

provided in a counseling center for women in the Negev that are based on feminist treatment models, and highlight the particular needs and preferences of women seeking mental health care. Finally, Mirsky presents a model for cultural-competence training for mental health professionals that is based on both theoretical and personalexperiential exposure to cross-cultural encounters.

Notwithstanding the efforts included in this special issue, and the rich contributions of early (e.g., Palgi, 24) and contemporary researchers (Bilu, 25; Greenberg, 26, 27; and Witztum, 28), further empirical research is needed to deepen the understanding and abilities to provide culturally-adequate care for our diverse populations.

We thank all the authors for their willingness to contribute to this special issue, and hope it will provide a basis for a continued informed development in cultural psychiatry by researchers and practitioners alike.

References 1. Levav I. Psychiatric and behavioral disorders in Israel. Jerusalem: Gefen, 2009.

2. Israel Central Bureau of Statistics. 2012. www.cbs.gov.il (accessed April 2, 2012).

3. Cohen AB. Many forms of culture. Am Psychol 2009; 64:194-204.

4. Geertz C. The interpretation of cultures. New York: Basic Books, 1973.

5. Eccles J. Expectancies, values and academic behaviors in achievement motives. In: Spence J, editor. Psychiatric disorders in America. San Francisco, Cal.: Freeman, 1983.

6. Lukoff D, Lu FG, Turner R. Cultural considerations in the assessment and treatment of religious and spiritual problems. Psychiatr Clin North Am 1995;18:467-485.

7. Almeida RV, editor. Expansions of feminist family theory through diversity. New York: Haworth, 1994.

8. Mays VM, Cochran SD. Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. Am J Public Health 2001;91:1869-1876.

9. Averbuch E, Kaidar N, Horev T. Inequalities in the health system and ways to cope with them (Hebrew). 2010. http://www.health.gov.il/download/ pages/briut_sofi.pdf (accessed June 21, 2011).

10. Krenawi A. The epidemiology of mental health disorders among Arabs in Israel. In: Levav I, editor. Psychiatric and behavioral disorders in Israel.

Jerusalem: Gefen , 2009.

11. Mirsky J. Mental health implications of migration. Soc Psychiatry Psychiatr Epidemiol 2009; 44:179-187.

12. Nakash O, Levav I, Gal G. Common mental disorders in immigrants and second-generation respondents: Results from the Israelbased-World

150

Mental Health Survey. Int J Soc Psychiatry 2012 May 7 [Epub ahead of print].

13. United Nations. The Convention on the Rights of Persons with Disability.

2006. http://www.un.org/disabilities (accessed May 18, 2010).

14. Alegria M, Canino GP, Pescosolido B. A socio-cultural framework for mental health and substance abuse service disparities. In: Sadock BJ, Sadock VA, Ruiz P, editors. Comprehensive textbook of psychiatry.

Baltimore: Wolters Kluwer Health, Lippincott Williams & Wilkins, 2009.

15. Nakash O, Rosen D, Alegría M. The culturally sensitive evaluation. In: Ruiz P, Primm A, editors. Disparities in psychiatric care: Clinical and cross-cultural perspectives. Bethesda, Md.: Wolters Kluwer Lippincott Williams and Wilk, 2009.

16. Department of Health and Human Services (DHHS). Mental Health: Culture, Race and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Maryland: USDHHS, SAMSHA, CMHS, 2001.

17. Westermeyer J, Janca A. Language, culture and psychopathology: Conceptual and methodological issues. Transcultural Psychiatry 1997;34:291-311.

18. Maxie AC, Arnold DH, Stephenson M. Do therapists address ethnic and racial differences in cross-cultural psychotherapy? Psychother Theor Res Pract Train 2006;43:85-98.

19. Kirmayer LJ, Groleau D, Guzder J, Blake C, Jarvis E. Cultural consultation: A model of hental health service for multicultural societies. Can J Psychiatry 2003;48:145-153.

20. López-Ibor Jr JJ. Cultural adaptations of current psychiatric classifications: are they the solution? Psychopathology 2003;36:114-119.

21. Fabrega H. Cultural psychiatry: international perspectives. Epilogue.

Psychiatr Clin North Am 2001;24:595-608.

22. Lee S. Socio-cultural and global health perspectives for the development of future psychiatric diagnostic systems. Psychopathology 2002;35:152-157.

23. Alegría M, McGuire T. Rethinking a universal framework in the psychiatric symptom-disorder relationship. J Health Soc Behav 2003:257-274.

24. Palgi P. Persistent traditional Yemenite ways of dealing with stress in Israel.

Ment Health Soc 1979;5:113-140.

25. Bilu Y, Witztum E. Working with Jewish ultra-orthodox patients: Guidelines for a culturally sensitive therapy. Cult Med Psychiatry 1993;17:197-233.

26. Greenberg D, Witztum E. Sanity and sanctity: Mental health work with Ultra-Orthodox in Jerusalem. Yale: Yale University, 2001.

27. Greenberg D, Shefler G. Obsessive compulsive disorder in ultra-orthodox Jewish patients: A comparison of religious and non-religious symptoms.

Psychol Psychother 2002; 75:123-130.

28. Witztum E, Goldman Y. Narrative construction of distress and therapy: A model based on work with Ultra-Orthodox Jews. Transcultural Psychiatry 1999; 36:403-436.

Ora Nakash, PhD,1 and Itzhak Levav, MD2 1

School of Psychology, Interdisciplinary Center (IDC), Herzliya, Israel

2

Ministry of Health, Jerusalem, and Department of Community Mental Health,

Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel

Isr J Psychiatry Relat Sci - Vol. 49 - No 3 (2012)

Utilization Patterns of Ambulatory Psychiatric Services by Ethiopian Immigrants in Israel Rafael Youngmann, PhD,1,2 Ina Pugachova, MPH,3 and Nelly Zilber, D ès Sc2 1

Ruppin Academic Center, Emek Heffer, Israel The Falk Institute for Mental Health Studies, Jerusalem, Israel 3 Department of Information and Evaluation, Ministry of Health, Jerusalem, Israel 2

Introduction

ABSTRACT Background: Ethiopian immigrants in Israel (EI) have limited familiarity with Western psychiatric care and, reciprocally, their culture is hardly known by mental health professionals.

Objective: To compare utilization patterns of ambulatory psychiatric services in Israel by EI and other population groups.

Methods: EI, former Soviet Union immigrants and Israel-born users of the 64 psychiatric governmental clinics and of the nationwide psychiatric rehabilitation services were compared on demographic and clinical data. Data were obtained from the Ministry of Health for the years 1997-2003.

Results: Among the EI cared in psychiatric clinics, there was a greater proportion of users with psychotic disorders; a lesser proportion was referred by self, family or friends; a greater proportion was prescribed psychotropic medications; and a lesser proportion received individual psychotherapy. EI used more protected housing facilities and less social and leisure services.

Discussion: Patterns of utilization of both types of services were found to be different among EI, suggesting a need to develop culturally-sensitive programs for both the Ethiopian immigrants and the mental health professionals.

Address for Correspondence: rafiyoung@ruppin.ac.il.

Immigrants, such as those Israel has received over many decades, have to overcome multiple challenges in their process of adaptation to their new home, e.g., culture bereavement, culture shock, language barrier, discrepancy between hopes and realizations, and non-acceptance by the people of the host society. Also, there is considerable evidence from studies in Australia, Israel, North America and Western Europe, that immigration is a risk factor for mental ill-health (1-5). However, despite the higher rates of emotional distress and psychiatric disorders (1, 6, 7) among immigrants than among the non-immigrant populations, an indication of a higher need for psychiatric care in immigrants, studies showed lower rates of use (8-13), even in countries with universal health insurance (14-17).

The rate of mental health service utilization by immigrants is even lower for those emigrating from developing countries, such as African countries, that are unfamiliar with the services in the host society (18). Thus, it is not surprising that the pattern of psychiatric hospitalization differs among Ethiopian immigrants (EI) in Israel, as compared to former Soviet Union immigrants (FSUI) and the Jewish Israel-born (IB) (19). Analogous findings have been made in other countries, comparing among different groups of immigrants, and between them and the native-born (18, 20). In addition, clinical interventions with users from developing countries have been shown to be often ineffective, particularly because these patients drop treatment against the advice of their clinicians more often than their native Western counterparts (21-23). Furthermore, there is abundant evidence that immigrants often receive culturally inappropriate care, or experience multiple barriers to care

Rafael Youngmann, PhD, Department of Behavioral Sciences, Ruppin Academic Center, Emek Heffer 40250, Israel.

151

Utilization Patterns of Ambulatory Psychiatric Services by Ethiopian Immigrants in Israel

(24-26). For example, Kirmayer et al. (27) have shown that the language barriers and cultural complexity (in particular culture-specific idioms of distress, 28) lead to cultural misunderstandings that may prevent adequate diagnosis and treatment.

Because immigrant populations from developing countries suffer from both the process of immigration and from the cultural gap between the host country and the country from which they emigrated, a way to study the effect of cultural differences on mental health service use is to compare two immigrant populations, one from a developing country and one from a developed country, while a comparison with non-immigrants allows taking into account the effect of immigration.

In Israel there is a unique opportunity to conduct such a study since it is a country of immigrants: over one third, 35%, of its population are immigrants, who came from different countries with marked cultural differences, while most of the non-immigrant population is composed of second-generation immigrants (29). Between 1984 and 1995, Israel absorbed 803,000 immigrants, most of them from the FSU and Ethiopia (30). According to Israel’s Law of Return, Jews living anywhere are entitled to immigrate to Israel and receive immediate Israeli citizenship.

To provide the new immigrants with language training, shelter, and livelihood has been part of Israel’s mission since the State was founded. Despite this support, higher psychological distress and psychiatric morbidity were consistently found among both FSU immigrants and EI compared to the Israel-born (9, 10, 31-37).

The objective of this study was to compare the pattern of use of ambulatory psychiatric services (outpatient psychiatric clinics and psychiatric communitybased rehabilitation services) among immigrants from Ethiopia (EI) and among two contrasting populations, the immigrants from the FSU (FSUI) and the nativeborn Israeli Jews (IB).

Methods Participants. The study included adult EI and FSUI who arrived to Israel between 1990 and 1991, and IB. All participants received psychiatric care during the years 1997-2003 in one of the country's 64 psychiatric governmental outpatient clinics or utilized psychiatric community-based rehabilitation services during the years 1997-2003. All services were provided cost free.

The clinic analysis consisted of two stages: 1) in the first stage, the study population refers to all the applica152

tions for care during the study period, so that the same individual could have more than one application during this period; and 2) in the second stage, the study population refers to the clinic contacts during the study period. With regard to the use of the rehabilitation services, the study population consisted of users of sheltered housing, vocational rehabilitation and/or social or leisure activity during the study period.

Data collection. Unidentified personal data were obtained from the Department of Information and Evaluation of the Israel Ministry of Health: sociodemographic data, clinical data (psychiatric diagnosis) and service use data (for clinics: referral agency, number of contacts; type of treatment; profession of the mental health caregiver and adherence to treatment; and for the rehabilitation services: type of service used).

Analysis. Descriptive statistics were used. To promote reliability, psychiatric diagnoses were grouped into seven broad diagnostic categories according to the ICD-10 (38): schizophrenia or other psychoses (codes F20); affective disorders (codes F30); organic disorders (codes F01-F04); neurotic or personality disorders (codes F40 and F60); drugs and alcohol disorders (codes F10); mental retardation and developmental disorders (codes F70 and F80); and Z codes (persons who were admitted for evaluation).

The number of contacts per patient per year, an index used by the Ministry of Health, was calculated for each population group as follows: the total number of contacts during the year divided by the total number of outpatients who had at least one contact with a clinic in the corresponding year. This index was calculated for each year of the study (1997-2003), and the mean number of contacts per patient per year is the mean of the index for each of these seven years. The corresponding numbers are larger than those published by the Ministry of Health because of slightly different definitions, e.g., if a patient was in group therapy led by two caregivers, the number of recorded contacts was two and not one.

Results Outpatient psychiatric clinics

In the years 1997-2003, 1,878 EI, 7,860 FSUI and 60,814 IB applied for care in the 64 psychiatric governmental clinics.

The distribution of the applications by psychiatric diagnosis was found to be significantly different in the three population groups (χ2=2643.01; df=12; p≤0.0005):

Rafael Youngmann et al.

Table 1. Comparison of the Distribution (%) of the Applications to Mental Health Clinics by Diagnosis, in the Three Population Groups Diagnosis

Ethiopian Immigrants (n=1,542*)

Former Soviet Union Immigrants (n=6,354*)

Israel-born (n=49,235*)

Schizophrenia or other psychosis

44.0

18.2

23.8

Affective disorder

12.7

18.8

12.1

Organic disorder

2.9

13.1

2.4

Neurotic or personality disorder

23.3

35.4

40.7

Drugs or alcohol disorder

2.6

2.8

3.3

Mental retardation or developmental disorder

2.9

3.1

5.2

Z code

11.5

8.6

12.5

Total

100

100

100

*The numbers refer to applications for which a diagnosis was indicated in the file.

Table 2. Comparison of the Distribution (%) of the Applications to Mental Health Clinics by Referral Agency, in the Three Population Groups Referral agency

Ethiopian Immigrants (n=1,830*)

Former Soviet Union Immigrants (n=7,689*)

Israel-born (n=59,086*)

Self-referral

27.2

38.5

43.1

Family or friends

4.1

6.7

7.2

Mental health agency

19.7

10.8

13.4

General physician

26.3

33.1

19.0

Other health agency

6.8

4.6

6.2

Welfare agency

12.2

4.0

6.5

Other

3.7

2.3

4.6

Total

100.0

100.0

100.0

*The numbers refer to applications for which the referral was indicated in the file.

Table 3. Comparison of the Distribution (%) of the Patient Contacts by Profession of the Mental Health Caregiver, in the Three Population Groups Profession of the mental health caregiver

Ethiopian Immigrants (n=39,722*)

Former Soviet Union Immigrants (n=152,858*)

Israeli-born (n=1,798,856*)

Psychiatrist

48.7

58.0

34.8

Psychologist

5.4

11.2

18.5

Psychiatric nurse

25.5

12.5

15.0

Social worker

17.0

14.2

25.1

Occupational therapist

0.9

1.1

1.8

Other

2.5

3.0

4.8

Total

100.0

100.0

100.0

* The numbers refer to the contacts for which the profession of the mental health caregiver was indicated in the file

among the EI, the highest percentage of applications received a diagnosis of schizophrenia or other psychotic disorders, while among FSUI and IB the highest percentage of applications received a diagnosis of neurotic or personality disorder (Table 1).

The distribution of the applications to the clinics by

referral agency also was found to be significantly different in the three study groups (χ2=1198.92; df=12; p≤0.0005); the percentage of self-referrals or referrals by family or friends was smaller among the EI (31.3%) than among the FSUI (45.2%) and the IB (50.3%), while the percentage of referrals by a welfare agency 153

Utilization Patterns of Ambulatory Psychiatric Services by Ethiopian Immigrants in Israel

Table 4. Comparison of the Distribution (%) of the Patient Contacts by Type of Contact, in the Three Population Groups Type of contact

Ethiopian Immigrants (n=41,295*)

Former Soviet Union Immigrants (n=156,674*)

Israeli-born (n=1,820,585*)

Intake

14.5

13.6

9.6

Psychodiagnostic evaluation

1.1

0.8

0.8

Drug therapy

44.2

36.0

24.9

Individual therapy

18.1

28.3

32.3

Group therapy / follow up

10.7

12.3

24.0

Couple therapy / family counseling

0.4

0.9

1.5

Professional evaluation for legal processes

2.3

1.1

1.0

Home visit

2.1

0.8

0.8

Other

6.6

6.1

4.9

Total

100.0

100.0

100.0

* The numbers refer to the contacts for which the type of contact was indicated in the file.

was greater (12.2%, 4.0% and 6.5 % respectively) (Table 2). These differences were found, at different degrees, within each diagnostic group.

The distribution of the patient contacts in the clinics by the caregivers’ profession was found to be significantly different in the three population groups (χ2=43012.96; df=10; p≤0.0005). The proportion of contacts with a psychologist was lower and with a psychiatric nurse higher among the EI than among the users of the other two groups (Table 3).

The distribution of the patient contacts in the clinics by type of treatment was found to be significantly different in the three population groups (χ2=32299.74; df=16; p≤0.0005): the percentage of contacts with individual therapy was lower in the EI (18.1%) than among the FSUI (28.3%) and the IB (32.3%), while the percentage of contacts with pharmacotherapy was the highest (44.2%, 36.0% and 24.9%, respectively) (Table 4). The proportion of house visits among EI (2.1%) was more than twice larger than among the two other groups (0.8%).

The mean number of contacts per patient per year was found to be higher among the IB (19.9) than among both immigrant population groups (EI, 16, and FSUI, 12.4). A similar pattern was found among patients with a diagnosis of schizophrenia or other psychosis (the mean number of contacts per patient per year among IB, EI and FSUI was 24.2, 21.3 and 14.9, respectively), and among patients with diagnoses other than psychotic disorders (15.7, 10.8 and 9.9, respectively).

The proportion of contacts for which patients were scheduled an appointment but did not show was found 154

to be similar in the three groups: EI, 24.7%; FSUI, 21.2%; and native born, 25.5%.

Psychiatric community-based rehabilitation services

The number of people with a mental disability using the rehabilitation services during the years 1997-2003 by population group was the following: among EI, n=338; FSUI, n= 993; and IB, n=14,186.

The proportion of users of rehabilitation services in sheltered housing was significantly (χ2=47.730, d.f.=2, p≤0.0005) different in the three population groups, with a higher percentage among the EI (61.3%) than among the FSUI (41.7%) and the IB (44.4%). The proportion of those who used vocational rehabilitation services was also significantly (χ2= 94.220, d.f.=2, p≤0.0005) different in the three population groups, with a percentage similar among the EI (76.8%) and the FSUI (72.2%) and significantly lower among the IB (60.4%). The proportion of those who utilized social and leisure activity services was also significantly (χ2=117.876, d.f.=2, p≤0.0005) different, lowest among the EI (41.2%), higher among the FSUI (53.4%) and the highest among the IB (63.6%).

Discussion Both newcomers and Israeli-born residents have a freeof-charge access to the government outpatient psychiatric clinics and, if they meet the official criteria of being mentally disabled, to the mental health rehabilitation services. However, significant differences were found in

Rafael Youngmann et al.

the patterns of utilization of outpatient psychiatric clinics services and psychiatric rehabilitation services between Ethiopian immigrants, immigrants from the former Soviet Union and native-born Israelis. The strengths of the study reside in the fact that mass immigration (reducing the bias of self-selection, which exists in most studies) of two very different populations took place recently in Israel and in the existence of nationwide data on service use of psychiatric governmental outpatient clinics and psychiatric rehabilitation services during the years 19972003 in the Israel Ministry of Health.

Study weaknesses include the fact that the data on outpatient psychiatric clinics included only the outpatient psychiatric clinics owned by the government, i.e., not the psychiatric outpatient clinics in general or psychiatric hospitals, or those owned or subsidized by health insurance organizations. However, since the different types of psychiatric clinics are spread all over the country and people generally choose the clinic which is the closest to their home (39), it is reasonable to assume that the utilization patterns would be the same in most public outpatient psychiatric clinics that serve the three population groups.

Among the immigrants from Ethiopia who applied for treatment in governmental psychiatric clinics, the percentage with a diagnosis of schizophrenia or other psychosis was found to be higher than among FSUI and people born in Israel, while the percentage with neurotic or personality disorders was smaller. Among the EI, the percentage with a diagnosis of schizophrenia or other psychosis was found to be even higher than the percentage with a diagnosis of neurotic or personality disorders, while among FSUI and the native-born it was the contrary. Since a visit to a professional mental health worker implies some kind of awareness of ones’ mental health problems, it seems that the EI patients tend to consider that non-psychotic disorders do not justify visiting mental health professionals in public clinics and/or are not referred to services. FSUI and people born in Israel are apparently more aware and informed that mental health problems, such as neurotic or personality disorders, can be treated in outpatient mental health clinics. One cannot, of course, exclude the possibility of a misdiagnosis among EI, as documented for minority populations in Western countries (40, 41). A possible difference in the distribution of the diagnoses in the general population (2) is not likely to explain the significant difference between EI and other population groups in the diagnosis of applicants who turn to mental health clinics.

It is reasonable to hypothesize that an EI who suffers from psychiatric disorders other than psychotic disorders may seek help from other agencies, such as family physician, traditional healers or welfare agencies. Fenta et al. (18), in a random sample of 342 Ethiopian adults residing in Toronto, found that only 12.5% among those who suffered from a mental disorder received help from formal healthcare providers, mainly family physicians.

The authors report that the Ethiopians were more likely to consult religious leaders and traditional healers than medical professionals for emotional problems.

About two thirds of Ethiopian immigrants’ applications to mental health clinics were based on referrals from health and welfare agencies, while the frequency of self-referrals and referrals by family or friends was much lower (less than one third). These personal referrals were substantially less frequent than among the Israel-born and the FSUI. This might indicate less awareness of their psychiatric problems, disbelief in the ability of the mental health clinics to help them, lack of knowledge about relevant mental health services and/ or preference to avoid mental health services because of the stigma attached to mental health problems.

Indeed, other research suggests that Ethiopians tend to conceptualize some emotional problems as physical rather than problems needing psychiatric services (31, 32). Furthermore, psychiatric services in Ethiopia are extremely limited (42), which may explain the reduced awareness of such services.

Studies about stigma have documented (43) that mental disorders appear to be a considerably more important correlate of perceived stigma than chronic physical conditions, among persons with significant activity limitations, especially in developing countries.

In this respect, Israel is closer to developing countries (44). It is possible that, among EI, stigma related to mental conditions is still higher, because, in the Ethiopian culture, mental illness is highly stigmatized, not only concerning the person who is ill, but also for every member of the extended family (45).

The fact that EI are less likely to self-refer for services than others might explain the findings that in the mental health clinics, the percentage of patients with schizophrenia or other psychotic disorders is higher and the percentage with neurotic or personality disorders is lower among EI than among the other population groups: mental health or welfare agencies, which were the main referral source for EI patients tend to direct patients with schizophrenia or other psychosis 155

Utilization Patterns of Ambulatory Psychiatric Services by Ethiopian Immigrants in Israel

rather than patients with neurotic or personality disorders to mental health clinics.

Considering the distribution of patient contacts by mental health profession, in comparison to FSUI and Israel-born residents, EI patients were less likely to be treated by psychologists, who usually practice Western psychotherapy, and most likely to be treated by psychiatrists and psychiatric nurses, who probably primarily prescribe medications. This claim is confirmed by the fact that Ethiopian immigrants, compared to FSU immigrants and the Israel-born, were found to be mainly treated by drugs and to a much lesser degree by psychotherapy. Pharmacological treatment as a therapy of choice seems appropriate to some extent, since most of the Ethiopian immigrants in care in outpatient psychiatric clinics are diagnosed as suffering from severe mental illness such as schizophrenia or affective disorders (56.7%). Nonetheless, for other patients applying to clinics with less severe mental disorders, such as neurotic or personality disorders, the low utilization of individual psychotherapy among Ethiopian immigrants probably reflects the lack of adaptability of Western psychotherapy to the mental health needs of Ethiopian immigrants and/or their disbelief in the ability of a verbal therapy to relieve their psychological distress. It suggests that cultural factors, such as linguistic barriers, or cultural differences in perception of health and in help-seeking behavior (46), play an important role in choosing individual psychotherapy for treatment.

On the other hand, the small percentage of individual psychotherapy among Ethiopians might also reflect that there are not enough trained Ethiopian psychotherapists to help this population effectively. However, it is important to mention that mental health care providers in the government psychiatric outpatient clinics seem to direct more resources to Ethiopian immigrant patients, as indicated by a proportion of home visits to Ethiopian immigrant patients more than double that to FSU immigrants or Israeli-born patients, when these contacts are generally initiated by the care providers.

The average number of contacts per patient per year was found to be lower among both immigrant groups compared with the native born. It was higher among EI compared with FSUI despite the fact that individual therapy, for which there are usually more visits, was more frequent among FSUI than among EI. This trend was found both among patients with a diagnosis of schizophrenia or other psychosis and among patients with non-psychotic disorders. Although the reason for this is not clear, it is 156

very encouraging; an effort should be made to increase the probability of EI to turn to psychiatric clinics since, once in care, they do not tend to miss contacts for which they were invited more often than members of the other groups. Furthermore, EI patients tend to remain in care longer than other immigrants.

Concerning patterns of rehabilitation service use, our data related to the nationwide service use in the period 1997-2003, which includes the period following the beginning of the implementation of the Rehabilitation of the Mentally Disabled Law in January 2001 (47).

We found that the proportion of the mentally disabled entitled to get rehabilitation services who used sheltered housing services was relatively high among EI and substantially higher than among the FSUI and IB. The high proportion of sheltered housing service use might reflect the relative weakness of the Ethiopian family and community structure (48, 49), that could not help and take direct responsibility for their most vulnerable members. Since the family has an important role in the psycho-social process of rehabilitation, even when the mentally disabled are in sheltered housing (50, 51), it seems that the Ethiopian families should get more support and be guided to assure the rehabilitation of the affected family member.

Results of the study further show that a high proportion (about three quarters) of the mentally disabled Ethiopians and FSUIs entitled to get rehabilitation services used vocational rehabilitation services – significantly more than the Israel-born. It has been shown that vocational rehabilitation has a significant impact both on the rehabilitation of the individual and on the society, both socially and economically (52, 53). In this respect, the higher use of vocational rehabilitation services by immigrants, both from Ethiopia and FSU, might indicate that the door to integration in the new society is open, even for the weakest immigrants.

Looking at the distribution of social and leisure activity services for the mentally disabled in the three population groups, we found that relatively few EI used these services compared with FSUI, while the Israel-born used them the most. It is plausible that these services are culture specific and are not tailored to the special features of immigrants, in particular EI, as it is also the case with other specific cultural and minority groups, such as the Arab Israelis and the Ultra-Orthodox Jews (47).

Rafael Youngmann et al.

Conclusions The most striking finding of this study is the similarity between immigrants from the former Soviet Union and the Israel-born, whereas immigrants from Ethiopia were significantly different from both groups concerning the patterns of utilization of both psychiatric services and psychiatric rehabilitation services. This may indicate that help-seeking behavior and use of services is more influenced by culture than by immigration per se. Active efforts are needed to make the role of ambulatory psychiatric services accessible, available and culturally suitable to EI. Clinical recommendations include initiation of psycho-educational programs for families and the community; to increase the number of Ethiopian professional mental health providers; and to train other professionals about the Ethiopian social context and the meaning of the Ethiopian patients’ idioms of distress. These recommendations should result in more culturally-sensitive mental health services for Ethiopian immigrants.

Acknowledgements

This research was supported by a grant from the Institute of Immigration and Social Integration, Ruppin Academic Center, Emek Heffer, Israel.

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Isr J Psychiatry Relat Sci - Vol. 49 - No 3 (2012)

Mental Health and Mental Health Care for Jews in the Diaspora, with Particular Reference to the U.K. Kate Miriam Loewenthal, PhD Royal Holloway, University of London, New York University in London, Glyndwr University, Wales, Heythrop College, London University, London, U.K.

ABSTRACT Background: Suggestions are examined with regard to psychiatric epidemiology among Jews: raised prevalence of depressive disorder in men, low prevalence of alcohol related disorders and suicide, higher prevalences of obsessive-compulsive disorder and psychosis.

Methods: Demography, psychiatric epidemiology, service provision, use and barriers to use are described in the U.K., with brief comparison with other Diaspora communities.

Results: Prevalence of depression may be as high among Jewish men as among women. Prevalence of anxiety, alcohol abuse and suicide may be low by world standards. No clear picture emerges regarding OCD, psychosis and other disorders. Barriers to treatment seeking include stigma and mistrust.

Limitations: There are inadequate data with respect to many disorders, service uptake, and the effects of religiosity.

Conclusions: There is scope for more research on a range of issues, including psychosis, eating and childhood disorders, anxiety and depression, and service use. Risk factors include anti-Semitism.

Protective factors include family stability, social support and religion.

Introduction: U.K. Jewry Demography and Psychiatric Epidemiology There are approximately 13 million Jews worldwide, about 5½ million each in Israel and the U.S.A. The remainder are scattered worldwide, with significant

concentrations (¼ to ½ million) in France, Canada, the U.K., Argentina and Russia, and smaller concentrations elsewhere (1). Worldwide, about 80% are said to be Ashkenazim (“Western” Jews), 20% Sephardim, although definitions of these categories are variable. Of approximately 300,000 U.K. Jews, about 10% are estimated to be Sephardic (in the absence of published data, this estimate was offered by the U.K. Sephardic Chief Rabbi, Abraham Levy, in a recent conversation). About 2 /3 of U.K. Jews are concentrated in the Greater London area, and most of the remainder in larger provincial cities such as Manchester, Leeds and Birmingham.

However, there is wide scattering: there were some Jews in all but one of the 408 U.K. census districts in 2001 (2). About 2/3 of affiliations are to the orthodox United Synagogue and its provincial affiliates, with the remainder fairly evenly divided between other orthodox groups, particularly the strictly orthodox (haredi) Union of Orthodox Hebrew Congregations, and the Federation and Sephardi groups of synagogues, and the non-orthodox groups (Massorti, Reform, Liberal).

In this article, affiliative groups will be referred to as haredi (strictly-orthodox), (traditionally) orthodox, non-orthodox and unaffiliated. Numbers of unaffiliated Jews are hard to estimate, but it has been pointed out that a high proportion of Jews will affiliate in order to secure Jewish burial rites (3). Census data are treated with caution since some Jews were known to be wary of identifying themselves as such, in spite of encouragement to do so (4). While estimates of numbers of Jews are likely to be under-estimates, they may not be major under-estimates.

Jews are a small minority (0.5%) among the U.K.’s 62 million, and few compared with the estimated 3 million Muslims in the U.K., who thus outnumber Jews by about 10:1. There is an unusual feature of Anglo-

Address for Correspondence: Kate Miriam Loewenthal, PhD, Psychology Department, Royal Holloway, University of London, Egham, Surrey TW20 0EX, U.K. c.loewenthal@rhul.ac.uk

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Jewry, by comparison with virtually all other Jewish communities worldwide, namely that most Jews are affiliated with an orthodox synagogue, even though individual observance is not always strict. This level of orthodox affiliation implies a strong sense of Jewish identity, reflected for example in the relatively low rate of intermarriage: ž of married Jews have Jewish spouses (2). In other Diaspora communities, normative affiliation is not with an orthodox congregation, and levels of intermarriage are generally higher. Levels of education and prosperity are at or above U.K. averages (2), for example Jews were more likely than the general population to have a degree-level qualification, to be in full-time employment and to own their own homes. Family size is slightly below the U.K. norm of approximately two children per household. Among the haredim, levels of (secular) education and of prosperity are low, while family size is large (2, 5). Thus in Hackney, the principal haredi area, proportions of Jews with no qualifications, living in rented accommodation, and living in overcrowded conditions, were higher than the national average.

What about the psychiatric epidemiology in the U.K. Jewish community? Reliable data are scarce. Several suggestions have been made about psychiatric epidemiology among Jews, and we examine the U.K. evidence: raised prevalence of depressive disorder in Jewish men, low prevalence of alcohol related disorders and suicide, higher prevalences of obsessive-compulsive disorder and psychosis. Anxiety, eating and childhood disorders are also examined in this article.

Aims and Questions This article examines mental health and mental health care for Jews in the Diaspora, with a focus on the U.K. How are mental health issues affected by the Diaspora and particularly the U.K. context?

The U.K. is the focus since systematic searches for work on Jewish mental health in the Diaspora yield rather fragmentary results. The author has a more detailed knowledge of the situation in the U.K., both from her own research and from work and other experience in the community.

Occasional reference will be made to work in other Diaspora countries and Israel, but this article does not aim to make detailed systematic comparisons with Israel, on which a mine of recently-gathered information exists (6).

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Depression and Gender Some years ago I was gazing in alarm at some research results. We had completed a survey of 339 U.K. Jews, involving lengthy life-events interviews and psychiatric assessments. The latter were estimates of caseness based on the Present State Examination (PSE) (7) using criteria similar to DSM-III. We found similar 12-month prevalence of (unipolar) depression among men (10%) and women (13%) (8). Was there something wrong with our data? Most other work reported higher incidence and prevalence of depression among women, compared to men (9, 10): Worldwide, prevalence ranges from 3% to 17%, and 12-month prevalences are about twice as high for women (approximately 10%) as for men (approximately 5%) (9, 10). To my relief, other work was emerging that reported similar findings to ours, using DSM-III criteria: Jewish men are as likely as Jewish women to be clinically depressed (11, 12), although this is not universally the case (13). Among explanations of this effect are low levels of alcohol use among Jewish men, compared to men from other groups (8, 14, 15).

Moderate alcohol use may be an escape route from distress and depression (14, 15). Also, there are reported lower levels of physical violence among Jews than among other groups (16) which may reduce depression among women resulting from domestic violence.

A further factor is that Jewish men may be somewhat more willing than men from other groups to talk about symptoms of depression (17).

Alcohol and Substance Abuse Since the 1950s there has been work on the very moderate use of alcohol among Jews (18) – less than 1% of Jews in the U.S. are alcoholic, compared to 7% in the general population. It was suggested that the vulnerable position of Jews in society leads to an emphasis on self-control. Moreover the encouragement of drinking (and even occasional drunkenness) on prescribed religious occasions limits the use of alcohol. The drift from orthodox affiliation and practice has not been associated with a noteworthy rise in alcohol use or abuse, and it was suggested in 1980 that low use of alcohol among Jews was a persistent community norm (19). This may be exacerbated by genetic factors: a suggested basis is the alcohol dehydrogenase (ADH) enzyme, associated with an aversion to alcohol and a lower risk of alcoholism among Asians and Jews (20). Does low Jewish

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alcohol use persist in the U.K.? Low levels of alcohol use among U.K. Jewish men compared to men from other groups were reported in 1990 (14). Recently, a young (male) Jewish student in the U.K. described his bewilderment at the prolific use of alcohol by his nonJewish fellow-students: they seemed to enjoy getting drunk on a daily basis. In a 2003 U.K. study of Jews and Protestants, we noted that the Jews saw drinking and drunkenness as inappropriate for improving mood or socialising (21): “I find that there are better ways to unstress myself, I do not drink when I am low. When I am low, I seek insight. Alcohol does not guarantee insight or even elevated mood.”

“It’s (drinking alcohol/going to the pub) not the Jewish way of doing things – you go to a wedding or Bar Mitzvah to meet people” (21).

In the U.K., pubs (public houses licensed for the sale and consumption of alcoholic drinks) are a national institution. Jews saw these as wild and violent places.

Protestants (except for the more religious) saw pubs as places for socializing and relaxing, where a drink among friends is calming and helps one to forget worries. Jews, women and the more religious reported lower levels of alcohol use than Protestants, men and the less religious (22). Thus religious practice may reinforce culturally carried norms about alcohol use. What about abuse of alcohol? Loewenthal et al.’s (22) sample was composed of strictly and traditionally-orthodox Jews, and there was no evidence of alcohol abuse in this sample.

Does psychoactive substance abuse exist among Jews in the U.K.? While there are reports of this, particularly among adolescents, there are no systematic published data. A Chabad house in the London area with a wellestablished drugs helpline reported increased use from Jews (from 85 callers in 2008, to 168 in 2009) (23). This may possibly reflect increased drug use, or increased willingness to seek advice from this source, perhaps due to increased public awareness of the helpline.

Suicide While there are tragic instances of suicide among Jews under severe threat, suicide is normally forbidden under Jewish law. Suicide prevalence figures suggest that worldwide, suicide may be lower among Jews, and among other religious groups which prohibit suicide (notably Islam), than among other groups (24-26). In the U.K., fewer suicidal ideas and lower endorsement

of statements tolerant of or favorable to suicide were reported among Jews than among Protestants (27).

Obsessive Compulsive Disorder (OCD) and Other Anxiety Disorders There is a common suspicion that the detailed requirements of Jewish law may foster OCD. Is this true? Outside the U.K., it has been concluded that religion provides an arena for the expression of OCD among Jews and others (28, 29). It has also been shown that obsessional personality traits are associated with religiosity, but not clinical levels of OCD (30). However, there is no direct evidence on links between Jewish religious affiliation or practice, and OCD in the U.K. U.K. work reported elsewhere in this article found such negligible levels of OCD caseness that they could not be analyzed (31).

What about other forms of anxiety? In the U.K., 12-month prevalence of total anxiety disorders was 6% (31), which is towards the low end of the wide range (4.2%-17.2%), reported in other studies of anxiety prevalence, with 10.6% estimated for 12-month prevalence worldwide (32).

In the U.K. study, there were higher levels of borderline clinical anxiety among orthodox (both traditional and haredi) women (38%), compared to men (24%). Affiliation differences were negligible, as were gender and affiliation differences in case anxiety. Why was this? Orthodox women reported higher levels of eventfulness than men, and eventfulness was tied to anxiety. Eventfulness was a product of family size, a feature of haredi life, but the analyses indicated that it was not solely family size that generated anxiety. The traditionally-orthodox women had smaller families than the haredi women, but were as likely to report high levels of eventfulness and of anxiety. It was suggested that “strong obligation and commitment to family and community is as likely in the traditionally as in the strictly-orthodox” (31, 33, 34). Among the specific forms of anxiety, there were significant gender differences only in situational anxiety, again higher among women (25%) than men (13%). It remains to be seen whether these trends in anxiety are specific to the U.K. or apply to Jews elsewhere in the Diaspora.

One study (using a symptom checklist) reported low levels of anxiety among Soviet immigrants to the U.S. (35), but outside Israel there is limited other work on anxiety among Jews, and negligible attention on borderline anxiety. Provisionally, prevalence of total 161

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anxiety disorders may be relatively low among U.K. and possibly other Diaspora Jews.

Psychosis Are Jews – Ashkenazi or otherwise – more prone to psychotic illness than other groups? Although this suggestion has been floated in the past, it has recently been contended that there are genetic loci that contribute to susceptibility to schizophrenia, bipolar disorder, and schizoaffective disorders (36), and it is not apparent that Jews are more genetically susceptible than others. There is no evidence from U.K. Jews affecting this point.

Other Disorders: Eating Disorders and Childhood Disorders Are there other psychiatric disorders that may be more or less prevalent in Jews than in other groups of people.

What is the U.K. evidence? There is rising concern about eating disorders, particularly among adolescent girls¸ with concern expressed by mental health service providers and educators within the U.K. orthodox Jewish community. This brief overview will refer to the most salient eating disorder, anorexia nervosa. It is possible that girls within the haredi community are less subject to media pressure towards slimness than are other girls. Haredim are more isolated from the popular media, TV and internet. Thus haredi girls may be less prone to eating disorders. There is no U.K. evidence, though more disordered eating attitudes were reported among Jewish than non-Jewish adolescents in Canada (37). However, this sample included adolescents from across the religious spectrum so we can draw no conclusions about haredi girls. In the U.S. (38), less body dissatisfaction and shame regarding appearance were reported by religious Jewish women, compared to secular Jewish women, suggesting that the insulated religious group may protect from body dissatisfaction. This protection may be disappearing, though. The author has noted that U.K. haredi parents believe that overweight daughters will be less marriageable than slim girls, and some haredi young men have confirmed that they would prefer a shidduch (marriage introduction) with a slim girl. Moreover, there is endorsement by educators and community leaders for the encouragement of healthy eating and the avoidance of obesity, for valid health reasons. Thus there are cultural pressures within the haredi community towards dieting and slimness.

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But in spite of concern, there is as yet, no reliable U.K. evidence about the prevalence of eating disorders in the haredi or wider Jewish community.

Turning to childhood disorders, lower levels of childhood emotional and behavior disturbances were noted in a U.K. pre-school haredi sample (39) compared with other groups assessed using the SDQ. The SDQ (Strengths and Difficulties Questionnaire, a checklist measure) (40) assesses aggressive, anxious, withdrawn, hyperactive and (low) prosocial behavior. However, in another study on older U.K. haredi children and adolescents using the SDQ, teachers reported higher than average levels of hyperactivity and attention disorder among adolescent haredi boys (41). Perhaps the reported problems resulted from the expectation that haredi boys should spend long hours in religious study, with the under-resourced, under-funded schools unable to provide sufficient exercise facilities. Pre-adolescent children, and girls, who are not subject to the same pressures for extensive religious study, and who may have more exercise opportunities as a result of slightly more state funding assistance, were not reported to have raised hyperactivity and attention difficulties. Levels of economic privation among haredim are high, but their disturbing effects may be offset by family cohesion, social support and religious factors. There is scope for more exploration of levels of childhood disorders and their possible causes among Jews.

Although it has been suspected that Ashkenazi Jews might be genetically susceptible to autism, as to schizophrenia (42), this is now no longer certain. Childhood disorders – ADHD, autism, learning difficulties and others – need specialist, culturally-sensitive support and treatment, shortly to be discussed.

Lifestyle and Stress in Relation to Psychiatric Disorder Jewish lifestyle is distinctive, especially among the more religiously-observant. The orthodox will observe the Sabbath, holidays, the dietary and marriage laws, and will prefer their children to have Jewish education. Among the haredim, media exposure is very limited, particularly because of a wish to insulate from differing standards of sexual morality. The practice of charity – giving money and time to communal needs – is heavily valued (5), and more orthodox men attend regular public prayers.

Therefore, the religiously-observant – traditional as well as strictly-orthodox – will congregate in areas with

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religious amenities available: kosher shops, synagogues, schools, ritual bath-houses. Social life with other Jews will be readily available. The strictly orthodox may do little socializing outside their community. Occupations are consistent with religious practice and values, for instance teaching in Jewish schools, or running businesses meeting community needs. Especially for those with large families, finance may be a source of stress, but there is some welfare provision, including child benefit payments. Health care is free under the U.K. National Health Service, and some Jewish schools do now receive state aid. However, many Jewish schools do not, especially in the haredi sector, and the provision of Jewish education is a drain on parental and community resources (5, 8).

All the above has mental health implications. The main positive features of Jewish lifestyle include the benefits of religiosity, including protective religious beliefs, prayer, social support, and family stability.

There are negative mental health implications, but these overall would normally be outweighed by the benefits.

Negative aspects include the impact of family size when income is inadequate, the complex effects of low alcohol use, and the closed community. The closed community can result in the need to maintain reputations, thus fear of betraying imperfection and avoidance of help-seeking for mental health problems, sometimes resulting in a downward spiralling into a more severe mental illness.

Firstly, religiosity has been found in other culturalreligious communities, and in Jews in the U.K. and elsewhere, to be associated with better mental health (43-45). Underlying this overall effect are the benefits of trust in G-d, hope, prayer, spiritual support, and other positive coping beliefs (46). Some of these effects have been confirmed in the U.K. Jewish community (47).

Social support and family cohesiveness are also beneficial (41). Social support includes neighborly help from other community members, and specific culturallysensitive community services (48, 49).

Unlike in the wider (non-Jewish) community, family size - religiously encouraged among haredim - does not in itself make women or men vulnerable to depressive disorder (8). Indeed it has been reported that women with large families report some mental health benefits, for example better concentration, compared to Jewish women with smaller families (50). But financial hardship can impact negatively on mental health, especially when family size is large. In the U.K., men seem more vulnerable to this effect than women (8). And as described earlier, family size is associated with eventfulness, which is associated

with borderline case anxiety particularly among women (33). Family stability – as indicated by the relative rarity of family conflict, violence and divorce – is associated with low levels of case depression (34). As described, cultural norms mean that alcohol is not normally used for coping, and this may be a cause of raised levels of depression among Jewish men (15). The closed community entails effort of reputation-maintenance, which may impact on seeking help for mental health problems. Another facet of reputation-maintenance is the silence which surrounds child and domestic abuse. There is reluctance (on religious grounds) to report instances to the civil authorities, and unwillingness to believe that respected members of the community may have perpetrated abuse. These phenomena have received limited attention, except among professionals working within the community. There is some suggestion that physical and sexual abuse may be lower among Jews than other in other groups (16), but information is limited: systematic data may be hard to obtain, though as mentioned lower levels of family conflict were reported among the Jewish community in the U.K. (34).

This section looked at some lifestyle factors and their possible impact upon mental health. Effects are mixed, but possibly beneficial overall. There is certainly scope for a closer look at these effects.

Service Provision Mental health service provision is dominated by the National Health Service. In spite of imperfections and funding cuts, it still offers a generally high quality of health care to U.K. citizens free of charge. Mental health services are provided under the National Health Service via general practitioner (GP) (family medicine) surgeries, including medication, counselling, and referral to specialist psychiatric hospitals with in-patient and outpatient facilities. For minority groups there may be failures to meet cultural needs (51). Examples include professional misinterpretation of religious behavior, such as religiously-prescribed handwashing, as obsessional (52), and difficulties experienced by Jewish parents in getting culturally appropriate provision for children with special needs (49). Numerous Jewish charitable bodies have arisen, designed to meet the needs of the Jewish community. These range from the relative giants, Jewish Care and Norwood/Ravenswood, which cover the spectrum of mental health, special-educational and social service needs for the whole community, to a host of relatively small haredi organizations such as Chizuk, 163

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120 100

Figure 1: Percentage of UK strictly-orthodox Jews who have used, found culturally and religiously sensitive, and who would use different types of family support (from a sample of 210).

(Health pro=Health professional; CompMed=complementary medicine; MarrEd=Marriage education/guidance; THM=Taharat HaMishpocha, training and advice on Jewish marriage laws; SpecEd=special education professional; communal=communal support services)

80 60

Used

40

Sensitive

20

Wd use

Fr ie nd s Ro v Bo ok s S He hiu r al th Co p r un o s Co ello r m pM ed M ar rE d

TH Sp M e Co cE m d m un al

0

offering psychiatric support and preventive work, and Ezer LeYoldos, offering support and counselling for mothers of newborns (48). Rabbis and their wives offer considerable support and counselling (49, 53). In the private sector, there is a growing army of orthodoxJewish counsellors and psychotherapists.

To what extent are these different services used or avoided, and why? Figure 1 offers some comparison of the use, perceived cultural sensitivity, and willingness to use, for different services for family difficulties, as reported by 230 U.K. strictly-orthodox Jews (49). The sample comprised those who responded to a postal survey addressed to 1,500 households randomly selected from Union of Orthodox Hebrew (strictly-orthodox) congregation membership lists. The 14% response rate was considered satisfactory for a postal survey. The average number of children per household was 5.6, similar to that reported in other studies of strictly-orthodox Jews, supporting the possibility that the sample may be representative of strictly-orthodox Jews in the U.K. Unfortunately, there are no comparable data for other U.K. Jews.

The commonly-used forms of support are generally those regarded as socially acceptable and which carry little or no stigma. For psychological difficulties, there is an over-riding need to maintain personal and family reputation, as in other cohesive cultural-religious groups (54, 55). The stigma of mental illness may affect marriageability for the whole family. Attending a GP surgery is non-stigmatizing and is a popular option (49). Similarly, consulting a rabbi is also a 164

popular option. Visits to psychiatric clinics are made furtively and reluctantly, with fear of being misunderstood by non-Jewish or non-religious professionals.

Therefore, many personal and spiritual difficulties may not be addressed, unhelpful for therapeutic progress.

Culturally-sensitive services within the community involve a different set of problems – the risk that problems may become public knowledge (56).

“I would not see a counsellor in the community. I might find myself sitting next to her at a wedding.”

“I wouldn’t go to a support group in the community.

We live in a goldfish bowl.” (48) Further, there are fears that haredi and other Jewish therapists and support workers are somehow less “professional,” less well-trained and less discreet than professionals from the general community (48).

Solutions to these dilemmas include the training in cultural needs of professionals within the National Health Service, and in the educational support and social services. Private and voluntary sector service providers must be above reproach with regard to confidentiality and professionalism. Services for child and other domestic abuse need development.

Comparison with Other Diaspora Communities How does the situation in the U.K. compare with that in other Diaspora countries? Lack of studies using comparable research questions and methods make confident comparisons and conclusions difficult. There are some possible suggestions. First, where comparable information exists, psychiatric epidemiology among U.K. and other Diaspora Jews may have broadly the same features. Thus depression may be more common among Jewish men than among men from other groups, while anxiety, alcohol and substance abuse may be less prevalent. We cannot draw conclusions about psychosis or childhood disorders. Secondly, the provision of culturally-sensitive services is developing well in all or most Diaspora countries with significant Jewish communities. In particular, the development of psychotherapy appropriate to Jewishis progressing, possibly with diminishing stigma attached to seeking psychotherapeutic help. Childhood disorders present particular problems and often require costly solutions. This situation has a familiar flavor worldwide. Some Diaspora communities have hospital psychiatric service provision designed for the Jewish community. In Europe, there

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is now just one Jewish psychiatric hospital, the Sinai Centre in Amsterdam (57). Originally set up to provide support for Holocaust survivors, it now also provides support for non-Jewish survivors of war and genocide.

There are several Jewish centers for hospital treatment in the U.S., in which there are psychiatric facilities, for example the Barnes-Jewish hospital (58), staffed by Washington University doctors. The majority of Jews in the Diaspora who require hospital care for psychiatric disorders will not have a specifically Jewish facility available. It is not known how the provision of Jewish hospital facilities affects uptake, but the picture may be extrapolated from the situation in the U.K. Difficulties experienced in general psychiatric hospitals include the fear of cultural and religious misunderstanding, and lack of religious facilities. These barriers are overcome when culturally and religiously-sensitive services are provided. However, the uptake of Jewish services increases the fear of stigmatization (48).

Of concern for mental health is the reported rise in anti-Semitism in the U.K., elsewhere in Europe, and worldwide (59). Much of this is thrust forward by Arab anti-Israel sentiment. It was noted that approximately 21% of the social service needs and difficulties reported

by Jews were culturally-tinged, specifically Jewish, including problems directly or indirectly stemming from antiSemitism (60). Anti-Semitic incidents include epithets such as “dirty Jews,” “send them to the gas ovens (sic),” losing employment because of the need to be Sabbathobservant, and attacks by Muslims and others on Jews, which can have mental health consequences.

Conclusions Men may be as prone to depressive disorder as women, a tendency which has been noted in some other studies of Jews. Anxiety prevalence, alcohol abuse and possibly suicide are low by world standards. There are few U.K. data on the prevalence of the less common psychiatric disorders – such as psychosis and OCD – among Jews.

There is scope for more research on a range of issues, including eating and childhood disorders. Jewish lifestyle may protect from some difficulties, but gives rise to needs for special service provision. U.K. and other Diaspora Jews are vulnerable to mental health difficulties arising from cultural insensitivity and abuse. Protective factors include family stability, social support and religion.

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Isr J Psychiatry Relat Sci - Vol. 49 - No 3 (2012)

In the Aftermath of Trauma: A Community Study of Bedouin IDF Servicemen and Their Families Yael Caspi, ScD, MA,1 and Ehud Klein,MD1,2 1 2

Department of Psychiatry, Rambam Medical Health Center, Haifa, Israel B. Rappaport Faculty of Medicine, Technion -IIT, Haifa, Israel

ABSTRACT Background. Data are scarce on the effects of trauma and post-traumatic stress disorder (PTSD) on minority servicemen from non-Western communities and the indirect impact on their spouses and other family members.

Method. Interviews were completed with Bedouin servicemen in the Israel Defense Forces (N=317) and co-resident wives (N=129) and mothers (N=67).

Results. Servicemen had high levels of trauma exposure and PTSD. Aggression displayed by married servicemen fully mediated the strong and positive relationship between their PTSD and wives’ posttraumatic, depressive, and somatic symptoms.

Mothers’ more severe emotional distress was unrelated to sons’ diagnostic status, but positively associated with sons’ aggression.

Limitations. These include sampling method, crosssectional design, retrospective reports, and absence of data on onset of symptoms.

Conclusions. Profound cultural barriers to care require a proactive approach towards non-Western servicemen, including (1) identification and initial treatment of trauma-related symptoms before discharge, (2) community education, and (3) training primary care physicians to address PTSD and related problems among servicemen and their families.

Acknowledgement

The study was funded by a grant from the United Jewish Appeal Federation of New York as part of their community-based trauma relief initiative.

It has been suggested that veterans from minority ethnic backgrounds experience higher rates of post-traumatic stress disorder (PTSD) following war-zone duty than those from non-minority origins (1). However, findings from studies on U.S. veterans have been inconsistent and controversial, suggesting that the occasional observed differences in rates of PTSD among Latinos, African Americans, American Indians, and Asian Americans, compared to non-Latino whites are better explained by factors other than cultural (2). While data on the traumatic experiences and post-traumatic reactions of refugees from non-Western backgrounds have been accumulated, little is known about minority military or peacekeeping personnel from non-Western communities. Questions on the cross-cultural validity of PTSD and the urgent need to emphasize the role of culture in diagnostic considerations have been laid at the doorstep of the DSM-V committee (3). Furthermore, although the vicarious effect of combat duty and PTSD has been increasingly acknowledged (4), little is known about the well-being of spouses and other family members of servicemen in non-Western settings.

The current paper provides an overview of findings from a community-based study aimed to explore the trauma exposure of Bedouin men serving in the Israel Defense Forces (IDF) and the ensuing psychiatric and health-related effects on them and on the women cohabiting with them.

The Bedouin Israeli Community The Northern Bedouin tribes in Israel relinquished their nomadic lifestyle and settled in permanent communities under the British Mandate (5), forming alliance with the emerging Jewish state and participating in its security efforts since its establishment. Although of Arab ethnic-

Address for Correspondence: Yael Caspi, ScD, MA, Department of Psychiatry, Rambam Medical Health Center, P.O. Box 9602, Haifa 31096, Israel. y_caspi@rambam.health.gov.il

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ity and Muslim faith, the Bedouins remain separated by choice from other Arab sub-groups. They marry young, in unions prearranged within the extended patriarchal family. Although educated, women are commonly not gainfully employed (6), but rather stay socially confined to the tribal circle and remain subordinate in the home (7).

Multiple factors place the Bedouin servicemen at a high risk of developing trauma-related problems. First, they constitute the only non-Jewish group who serve in the IDF strictly on a voluntary basis and primarily in combat units (8). In addition, they are of the same ethnicity and religion as the Palestinians in the West Bank and Gaza, where most military activities in the last 20 years have taken place. This type of affinity with the enemy has been singled out as a potential added risk minority soldiers face in deployment to conflict areas, especially given the possibility of civilian casualties (9).

The growing ambivalence towards service in the IDF (10) is further fueled by the rising power of Muslim religiosity in this secular community, and the propagated view that service in an infidel army is a sin against the Koran (11). Similarly to other low status minority groups, Bedouin veterans face limited access to the type of resources that buffer the impact of traumatic experiences and have limited ability to employ whatever resources they do have in the broad community (12).

Finally, cultural values and norms form barriers to helpseeking behavior and use of mental health services (13).

Suppression of emotions is expected, and the expression of emotional pain is a sign of character weakness or pathological behavior. At the community level, the grieving rituals are limited to setting up a “grieving tent,” held open for visiting mourners for three days only. On the fourth day, routine functioning is resumed.

Traditionally, there are no anniversary ceremonies or memorial days, as Islamic tradition admonishes adherents for protesting “God’s will” by overt and excessive lamentation over the deceased (14). Adapting Jewish customs, memorial grounds dedicated for the Bedouin fallen soldiers were established by the State in the late 1990s, where ceremonies have since been held annually on Israel’s Memorial Day. Nevertheless, many community members do not attend.

Consequently, it is apparent that a better understanding of the trauma response in this previously unstudied group is central for early identification of trauma-related problems and relevant treatment approaches. This paper offers an overview of our findings by including the perspectives of three different sub-samples: first will be described 168

the type and rate of traumatic experiences the men were exposed to and their direct impact, in terms of formal psychiatric diagnoses, symptoms of post-trauma and depression, physical health and services utilization. Secondly, the vicarious effect of living with husbands traumatized and suffering from PTSD will be presented through wives’ emotional and somatic symptoms and health services utilization, with special consideration given to the role of husbands’ aggression. Finally, the wellbeing of Bedouin mothers whose unmarried sons reside with them in the parental home will be described and contrasted with the condition and experiences disclosed by the wives.

Methods Participants

The study was part of the Bedouin Community Outreach and Needs Assessment Project. The Bedouin village selected for participation is located in Israel’s North District; it is among the largest, includes five different tribal families, and functions as a local council.

A total of 372 men were identified, of whom 348 (94%) agreed to participate and 317 (91%) completed the interviews. Permission to interview the women, initially requested from the men, yielded completed interviews with 129 wives and 67 mothers (for single men). Data regarding women’s response/refusal rate are not available.

The 196 women were related to 221 men who represented 70% of all male participants. The majority of women (91.3%) were related to a single male participant, either husband or son, residing with them in the same household. Of the 17 women related to more than one participant, 12 had two, three, or four sons in the study and five had a husband in addition to one or more sons. For the purposes of statistical analyses, a single man was paired with each of these 17 women. The selection was guided by the severity of men’s post-traumatic symptoms as follows: men diagnosed with PTSD were selected over those with other DSM disorders (n=4); in the absence of PTSD, men with other DSM disorders were selected over those with no diagnosis (n=3: Major Depressive Disorder (MDD), MDD with alcohol abuse; MDD with General Anxiety Disorder).

Finally, among men with no DSM diagnosis, those with higher scores on the symptom scales for post-traumatic stress and depression were included (n=10).

Procedures

Door-to-door enrollment of potential participants from households identified as having members in IDF service

Yael Caspi and Ehud Klein

was carried out by recruiters representing all five tribal families in the village. Study descriptions in Hebrew and Arabic were handed out to all eligible households with a letter from the principal investigators explaining the study’s goals and guaranteeing confidentiality of information. Contact information sheets were filled for those who agreed to participate. Potential participants were then contacted by phone by the interviewers. Referrals to additional households were made by the participants themselves. Up to six contact attempts were made until a potential participant was considered to have declined participation.

Following face-to-face explanation of confidentiality issues and the study’s goals, participants completed informed consent forms approved by the hospital’s Institutional Review Board. All forms and instruments were back-translated into Arabic to ensure accuracy of translation. Following the conclusions from the elaborate preparations and key-informant interviews that preceded the data collection phase of the study, men were interviewed in Hebrew by two Jewish female graduate psychology students and the women were interviewed in Arabic by two ChristianArab female undergraduate law students. Interviews were conducted in the homes, separately for men and women. The interviewers were trained in conducting semi-structured and culturally-sensitive interviews by YC and another researcher. The women’s interviewers were blind to men’s responses. Questions were read aloud and responses hand-recorded by the interviewers. Monetary compensation equivalent to US$25 was received at the end of the 1.5-hour interview. Only the men were psychiatrically assessed for the presence of Diagnostic and DSM disorders. Those identified as suffering from PTSD or any other Axis I DSM disorder were offered a meeting with the corresponding author and a letter describing the study, the diagnostic process and its conclusion. Launched in 2003, the data collection phase of the study lasted approximately 18 months.

Measures

Current financial status was rated on an ordinal scale from Excellent (1) to Poor (5). A binary variable was created by combining replies of “fair and “poor” to indicate poor financial status (1) versus replies of “good,” “very good,” “excellent” (0).

Experiences of traumatic events were described on a list of 13 events corresponding to the broader definition of DSM-IV-TR Criterion A1 (15). These included combat (for the men), severe car accidents, other severe acci-

dents, sudden death of a close friend/relative, risk to one’s own life or the life of a close friend/relative, witnessing or experiencing assault, domestic violence or physical abuse in childhood and any other traumatic experiences. For women, an item referring to sexual abuse was included.

The Structured Clinical Interview for Axis I DSM-IV Disorders (SCID; 16) Hebrew translation (17) was administered only to men to determine DSM-IV (15) diagnoses. The 3-level variable of husbands’ diagnostic group (PTSD, Other DSM, No Diagnosis) was transformed for the inferential analyses to two dummy variables, the first comparing PTSD to no disorder, the second comparing other DSM disorders to no disorder.

The Screen for Post-traumatic Stress Symptoms (SPTSS) (18) a brief self-report screening instrument for PTSD symptoms, composed of 17 items, rated on a 10-point scale from “Never” (0) to “Always” (10) in response to “how much that thing has happened to you during the past two weeks.” Designed for use in clinical and nonclinical settings, the SPTSS employs simple language and is not keyed to a single event. In a validation study, the performance of the SPTSS in the men’s sample indicated equal sensitivity and specificity rates of 89% vis-à-vis a SCID diagnosis of PTSD, at a cut point of 5.50 (19).

The Hopkins Symptom Checklist-25(HSCL-25) (20), used to assess symptoms of anxiety and depression, is composed of 10 symptoms of anxiety and 15 symptoms of depression, rated on a 4-point scale ranging from “not at all” (1) to “extremely” (4). The Arabic version (21) was well-received among Palestinian primary health care patients in the Gaza Strip (22). Internal consistency in our sample was very good for both men (Cronbach’s α =.95) and women (Cronbach’s α=.89) Substance abuse was assessed only for the men, addressing cigarettes, beer, wine and hard liquor. As suggested by the key-informants, questions about drug use were avoided for two primary reasons: First, asking participants who are still in service a question about an illegal activity may inhibit cooperation and introduce distrust, and secondly, alcohol is considered to be the substance of choice and more prevalent in this community.

Physical health, health related functioning and utilization of health services were assessed by eliciting information on the presence of somatic symptoms and self‑perceptions of health and wellbeing, as well as by items adapted from the SF-36 (23) describing self-perceived limitations in work, family, and daily functioning due to physical and emotional health. Additional items referred to utilization of primary care and specialty health services.

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Feelings of guilt and shame were assessed (only with men) by four questions rated on a scale between 0 (“not at all”) to 10 (“extremely”): Degree of guilt and remorse regarding service-related events; Degree of shame related to current functioning; Degree of shame related to others thinking there is something wrong with you; Degree that shame interferes with your ability to do things and act as you wish.

Internal consistency was good (Cronbach’s α=.82).

Men’s aggression, as reported by the women, was constructed as an index measure from three items describing behaviors that increase in level of volatility: 1. irritable, angry or impatient reactions; 2. breaking things, slamming doors or losing temper (verbally); 3. physical fights.

The choice of these items was guided by concerns that women would refuse to answer a more direct question about husbands’ aggressive behavior. The frequency of each item was rated on an ordinal scale from “Never” (0) to “Most of the time” (4). Scores on all three items were added to construct a continuous measure of men’s aggression in the past six months, ranging 0-12. Internal consistency was fair (Wives: Cronbach’s α=.77; Mothers: .57).

Results Summary of findings from the men’s sample (N=317)

As described elsewhere (24) the 317 men averaged 30 years of age, were mostly married (57%) with an average of 3.4 children. The vast majority (75%) served in combat positions as (in descending order) trackers, in the infantry, in specialized units trained in urban fighting and in the border police. Those in combat positions tended to report nearly two years less of schooling and to stay, on average, four years longer in service. Overall, the average length of service was 70 months; 19% of the men have served less than one year, 43% between 1-4 years, and 38% between 5-27 years. Fifty-eight percent were discharged at the time of the interviews. Of those, 38% were unemployed. Very few (12%) were receiving benefits for some service-related disability.

The level of trauma exposure in this sample was very high, with three of four men exposed to at least one type of traumatic event of sufficient severity to potentially cause PTSD, and additional 22% reporting extremely stressful events. War trauma was reported by nearly 70% of the total sample and by 90% of those traumatized. SCID-based DSM-IV Axis I psychiatric disorders were identified in 27% of the participants and included: PTSD, diagnosed in 14.5% (20% of all traumatized); MDD alone or co-morbid with anxiety disorder was 170

diagnosed in 5.4% of respondents; alcohol abuse - in 6%, and other diagnoses, mainly general anxiety disorder and panic disorder, were diagnosed in 1%. Only two participants suffered from psychotic-like symptoms in conjunction with PTSD and substance abuse, respectively. More than half of the participants with PTSD manifested co-morbidity with MDD. Traumatized respondents, especially if they also had PTSD, were more likely to be married, to have served for longer periods and in combat units. Those with PTSD were significantly more likely to have been discharged by the time of the interview than respondents without PTSD, whether traumatized or not. Very few were diagnosed prior to the study and most have never discussed their traumatic experiences before (24).

PTSD was associated with rates of post-traumatic and depression symptoms placing this group at severity levels similar to those exhibited by psychiatric inpatients (18) and refugees and asylum seekers attending a psychiatric outpatient clinic (25).

The findings consistently identified PTSD and not trauma exposure alone as the determining factor in the impairment of emotional and physical health among the men studied. Compared to those traumatized without PTSD, participants with PTSD were more likely to smoke more cigarettes and drink more beers, to view their health status as poor and worsening, to report frequent illnesses, more conditions diagnosed by a physician such as ulcers, asthma, high blood pressure and ruptured discs and to have visited primary care and specialty care clinics more frequently during the preceding six months (24). Indeed, our participants resemble more groups at-risk than community samples (26). Frequent visits to primary care and to specialty care clinics were significantly more likely to be reported by those with PTSD than those traumatized without PTSD. Lifetime hospitalization for physical health problems was reported by more than half of the sample (24).

Use of psychiatric outpatient and inpatient treatment services was reported by only 8% and 3%, respectively, of the men’s sample. Although use of these services was more prevalent among those with PTSD, the actual numbers were very low: less than half of those diagnosed by the study as suffering from PTSD and only 5% of those diagnosed with other disorders utilized mental health services.

Diagnostic status in our sample was significantly related to all shame indices so that PTSD was always associated with higher levels of guilt and shame than men with other diagnoses and no diagnosis at all (27). Except

Yael Caspi and Ehud Klein

for service-related feelings of guilt and remorse, men with other disorders were significantly different than men with no diagnoses, establishing an intermediate status for the group of non-PTSD DSM diagnoses on all shame items. Due to high inter-correlations among these items, subsequent inferential analyses employed only shame related to others’ perception. Findings showed that, controlling for the effect of men’s diagnostic status, shame related to others’ perception was significantly associated with multiple health and functioning items, such as increased likelihood for poor or bad health status, more frequent occurrence of illness and more frequent visits to the primary care clinic, increased impairment in self-care, social relations, familial-role and daily functioning due to physical or emotional health problems (data available from corresponding author).

sis, Bedouin wives living with husbands suffering from PTSD were in a poorer financial status, exhibited more elevated post-traumatic stress and depression symptoms and reported more somatic complaints. However, neither husbands’ diagnostic status nor their aggression was related to wives utilization of health services (28).

In this Bedouin sample, findings clearly indicated that, accounting for wives’ financial status, personal adverse experiences and husbands’ trauma, the strong observed relationship between husbands’ PTSD and wives’ post-traumatic, depressive, and somatic distress was fully mediated by husbands’ aggression (28).

Comparison between mothers and wives

Sixty-seven mothers were interviewed for this study, all with single sons in IDF service who still reside in the family home. Independent samples t-tests revealed significant differences between the wives (n=129) and mothers (n=67) in age, education, and number of births (Table 1). Mothers also reported slightly more adverse/ traumatic events. A series of odds ratios (ORs) from unadjusted logistic regressions provided consistent indication of mothers’ poorer condition, as evidenced by their increased likelihood for lower financial status and poorer health status, more physician-diagnosed illnesses, somatic complaints and frequent utilization of primary care and

Summary of findings from wives’ sample (n=129)

Twenty-six women were living with husbands diagnosed with PTSD, 19 had husbands diagnosed with other DSM disorders, and 84 had husbands with no diagnoses. They were similar in age which averaged 31 years, reported an average of 11 years of education, and an average of nearly four births. Compared to wives whose husbands were diagnosed with other DSM disorders and to those whose husbands did not have any psychiatric diagno-

Table 1. Sample Characteristics and Comparisons between Bedouin Wives and Mothers of Men Serving in the IDF Total sample N=196

Wives n=129, 65.8%

Mothers n=67, 34.2%

Background characteristics

M

SD

M

SD

M

SD

Differencesa

Age

38.17

12.57

31.27

8.06

51.65

8.04

MD=-20.5*** t=-16.72 df=193

Years of schooling

8.28

4.72

10.66

3.15

3.75

3.84

MD=6.91*** t=13.49 df=194

Number of births

5.24

3.56

3.46

2.47

8.67

2.73

MD=-5.21*** t=-13.1 df=194

Sum of adverse events (out of 14)

2.00

1.42

1.85

1.37

2.28

1.50

MD=-0.43*

Sum of somatic complaints (out of 8)

3.73

2.54

2.85

2.26

5.43

2.18

MD=-2.58*** t=-7.67 df=194

Mean SPTSS

2.22

1.84

1.97

1.71

2.71

1.98

MD=-0.74** t=-2.72 df=194

Mean HSCL-25

1.83

0.48

1.74

0.45

2.01

0.48

MD=-0.28*** t=-3.98 df=194

n

(%)

n

(%)

n

(%)

t=-2.02 df=194

Financial status (fair/poor)

106

(54.4)

60

(46.5)

46

(69.7)

OR=0.38** 95% CI: 0.20-0.71

Health status (fair/poor)b

39

(20.0)

10

(7.8)

29

(43.9)

OR=0.11*** 95% CI: 0.05-0.24

Physician-diagnosed illnesses

61

(31.1)

18

(14.0)

43

(64.2)

OR=0.09*** 95% CI: 0.05-0.18

Frequent use of primary care services

101

(51.5)

57

(44.2)

44

(65.7)

OR=0.32*** 95% CI: 0.17-0.58

Men’s aggression

96

(49.0)

68

(52.7)

28

(41.8)

OR=1.55

b

95% CI: 0.86-2.82

Note. IDF=Israel Defense Forces; SPTSS = Screen for Post-traumatic Stress Symptoms; HSCL-25 = Hopkins Symptom Checklist-25. a Mean Difference (MD) from t-tests; Odds Ratio (OR) with associated 95% Confidence Interval (CI) from unadjusted logistic regressions. b Compared to good/very good/excellent; c Assessed by the women *p < .05 **p < .01 ***p < .001

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The Bedouin community study

Table 2. Type of Traumatic Experiences Reported Wives N=129

Type of trauma

Husbands N=129

Mothers N=67

Sons N=67

Sudden death of someone close

87 (67.4%)

111 (86.0%)

51 (76.1%)

54 (80.6%)

Near death of someone close

57 (44.2%)

81 (62.8%)

28 (41.8%)

53 (79.1%)

Witnessed severe assault of a stranger

27 (20.9%)

41 (31.8%)

20 (29.9%)

19 (28.4%)

Other

21 (16.3%)

27 (20.9%)

13 (19.4%)

6 (9.0%)

Car Accident

15 (11.6%)

57 (44.2%)

12 (17.9%)

13 (19.4%)

Witnessed domestic violence as a child

13 (10.1%)

21 (16.3%)

9 (13.4%)

9 (13.4%)

Beaten up by someone close

8 (6.2%)

35 (27.1%)

----

15 (22.4%)

Someone threatened to hurt or kill you

6 (4.7%)

30 (23.3%)

1 (1.5%)

13 (19.4%)

Life-threatening illness

6 (4.7%)

1 (0.8%)

14 (20.9%)

----

Severe physical punishment in childhood

4 (3.1%)

9 (6.9%)

2 (3.0%)

2 (8.0%)

Other severe accident

4 (3.1%)

16 (11.6%)

5 (7.5%)

3 (4.5%)

Stalked or harassed

3. (2.3%)

30 (23.3%)

1 (1.5%)

10 (14.9%)

Touched intimately against your will

1 (0.8%)

----

----

----

Military-related events

----

98 (76.0%)

----

39 (58.2%)

Table 3. Characteristics and Comparisons between Bedouin Husbands and Sons Serving in the IDF Total sample N=196

Husbands n=129, 65.8%

Sons n=67, 34.2%

Background characteristics

M

SD

M

SD

M

SD

Differencesa

Age

31.17

8.48

34.84

7.78

24.08

4.21

MD=10.76*** t=10.54 df=194

Years of schooling

11.46

2.36

11.15

2.57

12.07

1.75

MD=-0.93** t=-2.65 df=194

Months of service

75.36

79.62

96.04

89.0

35.54

30.62

MD=60.50*** t=5.40 df=194

Sum categories of traumatic events (0-5)

1.60

1.24

1.77

1.26

1.27

1.14

MD=0.50**

Mean SPTSS

3.38

2.78

3.44

2.82

3.26

2.73

MD=1.80

t=0.43 df=194

MD=0.04

t=0.40 df=191

Mean HSCL-25

t=2.72 df=194

1.66

0.63

1.68

0.65

1.64

0.60

n

(%)

n

(%)

n

(%)

Discharged

119

(60.7%)

90

(69.8%)

29

(43.3%)

OR=3.02*** 95% CI: 1.64-5.58

Unemployed

46

(23.5%)

34

(26.4%)

12

(17.2%)

OR=1.64

Trackers

87

(44.4%)

64

(49.6%)

23

(34.3%)

Infantry/Bedouin battalion

30

(15.3%)

16

(12.4%)

14

(20.9%)

Border/military police

26

(13.3%)

14

(10.9%)

12

(17.9%)

Non-combat

53

(27.0%)

35

(27.1%)

18

(26.9%)

PTSDb

32

(16.3%)

26

(20.0%)

6

(9.0%)

Other

31

(15.8%)

19

(14.7%)

12

(17.9%)

133

(67.9%)

84

(65.1%)

49

(73.1%)

95% CI: 0.78-3.43

Position in service χ2=6.06 df=3

DSM-IV diagnoses

None

c

χ2=4.09 df=2

Note. IDF=Israel Defense Forces; SPTSS = Screen for Post-traumatic Stress Symptoms; HSCL-25 = Hopkins Symptom Checklist-25. DSMIV=Diagnostic and Statistical Manual, 4th ed.; PTSD = Post-traumatic Stress Disorder. a Mean Difference (MD) from t-tests; Pearson χ2, Odds Ratio (OR) with 95% Confidence Interval (CI) from unadjusted logistic regressions. b including co-morbid with major depression and/or alcohol abuse c including major depression, alcohol abuse with or without depression, anxiety disorders *p < .05 **p < .01 ***p < .001

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Yael Caspi and Ehud Klein

specialty health services in the preceding six months.

Furthermore, mothers reported more severe emotional distress in the two weeks preceding the interview on both the PTSD symptom scale (sptss) and the depression/ anxiety scale (hscl-25). Mothers were twice more likely to receive mean HSCL-25 scores above the established cutoff of 1.75 (OR= 2.63, 95% CI: 1.41, 4.89, p<.01), associated with “caseness.” The only variable for which no significant differences were noted was the percent reporting men’s aggressive behavior (53% of the wives, 42% of the mothers). Although mothers were likely to report more adverse events, the distribution of experiences was quite similar to that reported by the wives (Table 2).

Differences between the 129 Bedouin husbands and 67 sons paired with the wives and mothers, respectively, were also explored (Table 3). As expected, husbands were older, spent more years in service, were more likely to have had more varied traumatic experiences and to have been discharged and unemployed by the time of the study. No differences were found in the percent who

served in combat positions. Nevertheless, sons were less likely to be diagnosed with PTSD than husbands (9% vs 20%), yet, on the average, husbands and sons manifested no significant differences in their post-traumatic and depression symptom scores.

Factors affecting mothers’ wellbeing

The impact on Bedouin mothers of co-habiting with sons exposed to military trauma and suffering from PTSD and other psychiatric disorders was explored in hierarchical regression analyses (Table 4). Mirroring the analyses conducted for the wives (28), we first controlled for mothers’ poor financial status and mothers’ and sons’ traumatic exposure in step 1, then entered the two dummy variables representing sons’ diagnostic status in step 2, and mothers-reported sons’ aggression in step 3.

The results of the hierarchical regression analyses (Table 4) indicated that, with no exceptions, sons’ diagnostic status was unrelated to mothers’ emotional and somatic distress. Rather, mothers’ poor financial status

Table 4. Summary of Hierarchical Linear Regression Analyses Predicting SPTSS and HSCL-25 Symptoms and Somatic Complaints for Bedouin Mothers SPTSS SE B

HSCL-25 β

B

SE B

Somatic complaints β

B

SE B

β

Variable

B

Step 1:

R2=.24 Adj R2=.20***

R2=.25 Adj R2=.21***

Poor economic status, mother

1.48

0.48

0.35**

0.27

0.12

0.26*

1.30

0.50

0.28*

Traumatic exposure, mother

0.38

0.15

0.28*

0.12

0.04

0.38***

0.67

0.16

0.46***

Traumatic exposure, son

-0.21

0.20

-0.12

-0.04

0.05

-0.10

0.07

0.21

0.04

Step 2:

R2=.24 Adj R2=.17

Poor economic status, mother

1.47

0.49

Traumatic exposure, mother

0.38

Traumatic exposure, son

-0.21

PTSD, son (dummy)

R2=.30 Adj R2=.27***

R2=.25 Adj R2=.19

R2=.33 Adj R2=.27

0.35**

0.27

0.12

0.26*

1.28

0.50

0.15

0.28*

0.12

0.04

0.21

-0.12

-0.04

0.05

0.38**

0.66

0.16

0.45***

-0.09

-0.01

0.22

-0.00

0.04

0.80

0.01

-0.03

0.19

-0.02

0.70

0.82

0.10

Other DSM disorders, son (dummy)

-0.04

0.59

-0.01

-0.04

0.14

Step 3:

R2=.31 Adj R2=.24**

-0.04

0.83

0.61

0.15

Poor economic status, mother

1.38

0.47

0.33**

0.25

0.12

0.24*

1.24

0.50

0.27*

Traumatic exposure, mother

0.24

0.16

0.18

0.10

0.04

0.29*

0.59

0.17

0.40***

Traumatic exposure, son

-0.27

0.20

-0.16

-0.05

0.05

-0.12

-0.04

0.12

-0.02

PTSD, son (dummy)

0.09

0.77

0.01

-0.01

0.19

-0.01

0.72

0.82

0.10

Other DSM disorders, son (dummy)

0.26

0.58

0.05

0.02

0.14

0.02

0.97

0.62

0.18

Husband’s aggression, mother

1.17

0.47

0.30*

0.24

0.12

0.05*

0.54

0.50

0.13

R2=.30 Adj R2=.23*

0.28*

R2=.34 Adj R2=.27

Note. F(6,64) = 4.39, p < .001 for SPTSS; F(6,64) = 4.20, p < .001 for HSCL-25; F(6,64) = 5.04, p < .001 for Somatic Complaints.

SPTSS = Screen for Post-traumatic Stress Symptoms; HSCL-25=Hopkins Symptom Checklist 25; PTSD = Post-traumatic Stress Disorder; DSM = Diagnostic and Statistical Manual. *p < .05 **p < .01 ***p < .001

173

The Bedouin community study

emerged as a significant and consistent factor, positively associated with their emotional and somatic distress even when all other variables were included in the model.

Mothers’ utilization of primary care services was unrelated to sons’ diagnostic status but was significantly and positively related to sons’ aggression (χ2=5.96, p<0.02).

Discussion This report provides an overview of findings from a study conducted within a Bedouin community in the Galilee, which offers the first and only systematic documentation of trauma exposure and its impact among Bedouin IDF servicemen and their families.

The pervasiveness of trauma exposure and PTSD identified among the Bedouin men by the door-to-door outreach efforts highlights the absence of specific and focused means for early identification of trauma-related problems in this unique cultural group. The rate of PTSD in our male sample (nearly 20% of those traumatized) is higher than reported for trauma-exposed men in U.S.-based epidemiological surveys (29) or among Israeli university students, the majority of whom were also exposed to trauma (30). Indeed, our participants resemble groups at-risk, such as Palestinians in the Gaza Strip (26) and peacekeeping forces (31), more than they do community samples.

In addition to exposure to adverse ethnic-related events during service (32), it has been suggested that minority servicemen may experience higher levels of combat stressors (33), as well as added difficulties in the readjustment period following discharge (34). The loss of status and employment that often follows military discharge is a wellknown problem for Bedouin ex-soldiers (12), and is exacerbated by the fragile balance of ethnic relations in Israel.

One of the participants in the study, a former high ranking soldier in one of the elite combat units, articulated this tension: “They called me ‘bro’ when I was in uniform. In civilian clothes, I am just another Arab.”

The vicarious impact on the Bedouin family was captured in this study by interviews with the women who live in the same households with our male participants. The plight of the wives is evident; higher rates of post-traumatic and depressive symptoms, somatic problems and increased utilization of primary care services convey quite clearly the burden of living with men whose emotional distress was severe enough to meet the criteria for PTSD or other diagnoses. The central role of husbands’ aggression echoes findings reported by several Western samples.

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However, a closer examination, preferably by qualitative methods, should be dedicated to the finding that aggression fully mediated the effect of PTSD on wives.

Clinical experience and the multiple interviews conducted in this community suggest that the marital bond in these traditional settings is one of the first casualties of the post-traumatic landslide. With societal codes that oppose processing and expression of emotions, the dangerous consequences of stigma, and lack of communal knowledge regarding the after-effects of trauma, wives are faced with the disintegration of the family lifestyle, yet have no coping strategies or support (28).

For many of our Bedouin patients who suffer from PTSD, the wife becomes the mirror that reflects the fallen, injured hero. Men, especially those who were fighters, report the debilitating effects of constant fear, chronic lack of sleep, inability to tolerate the children’s loud voices or the daily gatherings of family and friends.

The role reversal generates anger and shame; more than one patient shared with us the humiliation he feels when he awakens his wife to escort him to the bathroom at night because of fear of the dark. In addition to describing the conditions and welfare of Bedouin wives, the study attempted to explore the nature and relevance of the concept of “secondary traumatization.”

The literature on the impact on veterans’ families identified manifestations of post-traumatic pathology rather than combat exposure itself as responsible for family problems (35). Multiple studies have linked PTSD with increased likelihood for intimate partner violence and aggression within the family (36, 37) and with partners’ psychological maladjustment (38).

Several mechanisms may explain the crossover of stress between partners: 1. the presence of common stressors affecting both partners, such as financial problems, causing the pressure cooker effect (39); 2. indirect crossover moderated by interactions in which individual’s distress causes undermining behavior toward the spouse, resulting in her/his distress; 3. direct crossover that generates stress contagion by which the spouse experiences the individual’s distress through empathy.

In our sample, the explanation of the pressure cooker effect, caused by common stressors, could not be completely ruled out, especially because of the high rate of unemployment and drop in financial status associated with military discharge in this community. However, poor financial status was not shown to be related to wives’ distress. Direct empathic crossover is also not a likely explanation for the wives’ distress as Bedouin

Yael Caspi and Ehud Klein

wives are commonly unfamiliar with the men’s military activities, especially not traumatic experiences. It is much more probable that their secondary stress is related to the demands of living with a symptomatic husband, as described among spouses of Holocaust survivors who were children during World War II (40).

Indeed, the explanation most fitting the Bedouin couples in our sample appears to be indirect crossover, whereby husband’s ordeal exacerbates spouse’s psychological and physical distress due to his undermining aggressive behavior. The concept of Burden of Care, which has only minimally been studied among families coping with anxiety disorders (41), has been described in terms of its emotional, psychological, and physical impact, the experience of shame, embarrassment, feelings of guilt and self-blame (42). Wives of veterans with PTSD are faced with significant chronic stressors merely by living with a trauma-disordered person; they must cope with role reversal, lack of partnership, full responsibility for the family, and significant loss of their former life-style (43). For the Bedouin wife, there is no access to information about trauma or PTSD to help her name the problem and little support from a community concerned with stigma and oftentimes misunderstood by a culturally-insensitive mental health system (44).

The role of shame in the adaptation of the Bedouins to the impact and consequences of post-traumatic stress is of great importance, although no systematic study of it is available as of yet. In our clinical experience, shame is a critical dimension of post-traumatic pathology and the experience most consistently accountable for the enhancement of the already debilitating effects of PTSD (45) increasing the vicious circles of avoidance, subsequent isolation, loss of social support and self-loathing, shame can often be found at the root of chronic, treatment-resistant PTSD. Both shame and fear are biologically stressful experiences, yet shame is the organizing social force in cultures that are shame/honor-based (46). Indeed, in our men’s sample, the loss of personal resources (e.g., selfesteem, self-mastery) was found to be the best predictor of psychological distress (47). These findings underline the paradoxically significant value of personal resources within collectivist communities in coping with trauma and maintaining resilience, and support the view that the role of shame in traumatic disorders, especially in these settings, is a vital area for further study (48).

The observed differences between wives and mothers reflect genuine generational differences (8), as well as differences in culturally defined familial roles (49).

Although clearly not affected directly by sons’ distress as wives are by their husbands’, mothers’ overall poor health should be an issue of concern. Although the role of sons’ aggressive behavior was limited in this study to mothers’ level of depression, it may be just the tip of the iceberg for a much more complex problem. Anecdotal data suggest that Bedouin mothers are oftentimes not supportive of sons’ military enrollment, either due to being more religious or to a lesser involvement with events outside of the community. However, the implications of this potential conflict, once a son returns home with a psychiatric disability, are yet to be uncovered.

Limitations and Conclusions The study’s primary limitation involves its sampling method. All attempts to get a comprehensive listing of all IDF members in the village were unsuccessful.

Although exceeding our expectations, the high response rate in the men’s survey cannot compensate for the possibility that households not included or women not interviewed were different in some meaningful way from our participants.

Another limitation is the study’s cross-sectional design and the absence of data on onset of symptoms for both men and women. Our impression was that for most men, PTSD had a delayed onset, following discharge, thus disconnecting even further the post-traumatic manifestations from the traumatic events. Indeed, during the interviews with the men, the most prevalent explanatory model for their symptoms appeared to center around retribution and reprisal, drawing on the ancient justice of “eye for an eye, tooth for a tooth.”

As explained by one participant: “Even though I had no choice and my life depended on it, taking the life of another human being is an act I have to pay for, and if not I, then my children, or my children’s children.”

Although the Bedouins in Israel deal with a unique set of circumstances, the issues they face are relevant for other ethnic and cultural minority groups in military service.

Participation by indigenous people in the military has been the focus of an in-depth and remarkable investigation undertaken by the Canadian Forces that explore the relationship between Aboriginal peoples and Western militaries from a cross-cultural perspective (50, 51). Valuable lessons can be learned from North American’s Indians or First Nation communities, the Aborigines of Australia, the Maori of New Zealand and other such culturally distinct groups that supported the war efforts of nation-states 175

The Bedouin community study

responsible historically for their displacement and exploitation. Whereas assimilation of these aboriginal populations, entailing their conversion to Christianity and the elimination of their distinctive cultural patterns, was an objective of colonial institutions (52), the socio-cultural and religious segregation of the Bedouin communities from the Jewish majority is endorsed by all. As a result, the conservative, non-Western lifestyle typical of Bedouin and other Arab communities is maintained in parallel to the dominant Western majority culture, with only restricted, mostly commerce-based interactions.

Consequently, it is necessary that early identification of trauma-related problems and intervention efforts with this community will be formed with the understanding that integration into the majority culture is unlikely to occur in the near future. Indeed, one of the most alarming findings in this study is that those most in need of trauma-informed care refrain from utilizing mental health services. Moreover, given the profound cultural barriers to care, a three-fold proactive approach should be undertaken: 1. Trauma-related problems should be addressed during the military service and issues related to re-entry into civilian life should be discussed, 2.

Community education, specifically for women, about trauma and PTSD should be introduced in order to reduce the impact of shame and the fear of stigma, 3.

Primary care physicians, a resource easily utilized in traditional communities (53), should be educated in order to identify PTSD, domestic problems, depression and alcohol abuse among their minority patients.

Finally, the disruption in family life caused by the returning veteran’s PTSD has been well documented (4) and the long-term risk for the children has also been suggested (54). Trauma-related needs should therefore be addressed effectively, comprehensively, and early enough in order to prevent the ever growing circles of loss and cross-generational transmission. In native societies, these issues are commonly further amplified by the myriad of adversities already at their doorstep.

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Isr J Psychiatry Relat Sci - Vol. 49 - No 3 (2012)

Successful Cultural Change: The Example of Female Circumcision among Israeli Bedouins and Israeli Jews from Ethiopia RH Belmaker Beersheva Mental Health Center, Ben-Gurion University of the Negev, Beersheva, Israel

ABSTRACT Female genital mutilation (FGM) is practiced in many areas of the world, including the Middle East, Africa and Australia.

Although it is most common in Muslim populations it is not a dictate of Islam. In the 1980s this practice was reported among Bedouin tribes, originally nomadic, in the southern area of Israel. Almost all of the women interviewed in the first study intended to continue the practice by performing FGM on their daughters including educated women who were teachers, dental assistants or university students. A second study was therefore done based in the obstetrical clinic where only women from tribes reporting to undergo FGM were examined for signs of FGM by an experienced gynecologist, in the presence of an Arabic-speaking female nurse and translator, as part of a gynecologic examination that was indicated for other reasons. In no cases was clitoridectomy or any damage to the labia found. All women had a small scar from a 1cm. incision somewhere on the labia or prepuce of the clitoris. This study concluded that the importance of the ritual in this population was unrelated to its severity. The ritual had apparently become over time a small symbolic scar, even though this population continued to believe in its importance.

By contrast, a group of Ethiopian Jews who had immigrated to Israel was interviewed by an Amharic translator, and examined during routine gynecological examination in the same manner as the Bedouin group above. In Ethiopia, FGM is universal among Christian, Muslim and Jewish groups. All women interviewed reported that FGM was universal in Ethiopia, but none intended to continue this practice with

their daughters. All stated that this was a practice that would be left behind in their country of origin. On physical examination many of the women had amputation of the clitoris. The conclusion of this study was that the severity of the operation performed had no relation to the social and cultural adherence to the operation, since the Ethiopian Jews who practiced a more severe form of the operation intended to abandon this practice while the Muslim Bedouin who had a much milder form intended to continue it.

A follow-up study in 2009 of the Bedouin population of southern Israel has found that FGM had disappeared, both by self-report of women under the age of 30, and by physical examination of women under the age of 30 in an obstetrical clinic. These results suggest an optimistic approach toward cultural change involving unhealthy cultural practices and emphasize the importance of cognitive approaches to cultural change.

Introduction Female genital mutilation (FGM) is a practice that is still prevalent in many parts of the world. It has been described in different ethnic groups living in Africa and Asia (1). It is performed more widely than is generally recognized, although many in the Western world are unfamiliar with the procedure (2). Two primary care physicians working with Bedouin patients living in Israel came in contact with two patients with medical complications of FGM (bleeding and infection). They then conducted a preliminary study to estimate the

Address for Correspondence: RH Belmaker, MD,Beersheva Mental Health Center, PO Box 4600, Beersheva 84170, Israel. belmaker@bgu.ac.il belmaker@bgumail.bgu.ac.il

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prevalence and motivation for FGM and physical findings after FGM (3).

FGM is practiced in variable forms among different peoples. The most extreme practice is the Pharaonic operation, also called infibulation, in which the clitoris is removed along with the labia minora and at least two-thirds of the labia majora (4). A less drastic form of FGM is called the Sunni type, and involves removal of the prepuce of the clitoris, similar to male circumcision.

The two forms are not clearly separated anthropologically and many groups practice intermediate forms (1).

Lightfoot-Klein (4) described the practice of FGM in the Sudan, where the Pharaonic type is normative.

Through structured interviews but without physical examination, she attempted to evaluate the motivation of the women and men for the procedure and its effect on sexual function and health. Lightfoot-Klein collected information over five years in multiple settings in a nonsystematic manner in Sudan. In our 1995 study (3) we attempted a more systematic approach to allow separation of family myth from present practice.

In particular, physical examination of a sample seemed critical to confirm or disconfirm subjective impressions of the nature of the FGM performed, since the practice is so variable.

1995 Study Twenty-one Bedouin Arab women were interviewed in the Arabic language by a female social worker trained in human sexuality. Women were recruited for interview on recommendation of the Medical Clinic staff as individuals willing to cooperate and who were thought to know about FGM (“community leaders”). The usual term used in the interviews for FGM was not anatomic but the Arabic word “purification.” The interviewing was done in two steps. The first was in groups of five to six women, since the women refused to talk to an outsider alone. The second phase of the interviewing was individual. Each consenting woman was asked about personal details, medical information, beliefs about FGM, and history of her own FGM. The nature of the interview by a non-Bedouin in an undefined setting elicited more information about cultural norms and accepted practice than about personal sexual feelings and experience. None of the women could anatomically describe what part of their female genitalia has been altered or in what way. The nature of the interview was more anthropological (i.e., eliciting beliefs and attitudes

felt to be normative) than psychological (i.e., evocative of the individual’s personal history and inner feelings).

Separately, a physical examination was conducted on a sample of 37 women (ages 17-36) from tribes reported to undergo FGM by the original groups of interviewed women (3). The physical examination was conducted during gynecological examination by an experienced gynecologist as part of a comprehensive obstetric or gynecologic examination in the presence of an Arabicspeaking female nurse and translator. In all cases the introitus was carefully examined, the prepuce lifted, the clitoris observed and the labia separated and individually examined for damage or scars.

The sample was a consecutive and unbiased sample of all women attending the clinic from the tribes reported in the previous interview study to perform FGM. No women refused to participate. The sample included 27 housewives, 2 teachers, 1 dental assistant, 4 factory workers, 1 secretary and 2 university students. Age of the women interviewed ranged from 16 to 45 years. All were Muslims, belonging to six different tribes: one black tribe originating from Africa, the others were Caucasian originating from Egypt or Saudi Arabia.

The interviewed women reported that they themselves, all their sisters and the women in their close and extended family underwent FGM. The older women who had daughters reported that the daughters had already undergone FGM or will have FGM when they reach the suitable age. The age of FGM is 12 to 17 years, after menarche but before marriage.

The primary decision-maker for FGM is the mother.

When the age of FGM is reached, “pressuring” remarks are made to the girl. These remarks concerning her cooking and baking imply that the food she is preparing is not clean or tasty, and from this she can understand that FGM is needed. The FGM is performed mostly by old women who are known in the tribe as the traditional surgeons. One of the interviewed women performed FGM on herself!

The girl to have FGM is held by two women, one holding her hands and closing her mouth to prevent crying or screaming, the other woman holding her thighs apart. Water and soap are used to clean the external genitalia. A razor is usually used to perform FGM, without anesthesia.

Several reasons are given for FGM. The most common is social pressure to maintain tradition. The second most common is the belief that women without FGM are not good bakers or cooks. Many women believe 179

Cultural changes and female circumcision

that after FGM women are cleaner (the Arabic word for FGM is tohor – purification). Other less common reasons given for FGM include enhancement of reproductive ability and decreasing a women’s sexual desire. Men are empathically not involved in FGM, according to all informants. Fathers are not aware of whether daughters have had FGM, and husbands-to-be do not inquire and are not told. It is strictly a women’s issue.

Most of the women stated that they will continue practicing FGM on their daughters. Two young women age 16 and 18 years said they will not perform FGM on their daughters: They were the younger and better educated women in the group we studied.

On physical examination of 37 women other than those originally interviewed but from the same tribes, none were found to have had clitoridectomy or removal of the labia majora or minora. All had small scars apparently from old incisions, on the prepuce of the clitoris or the upper 1 cm. of the labia minor near the clitoral prepuce. On the clitoral prepuce there were scars in 25 women, always vertical up to 1 cm in length and in the midline. In 31 women there were scars, horizontal less than 1 cm in length, on the upper labia minora, right or left side, below the clitoral fold. In six women from the most educated families there was a single scar on the clitoral prepuce or the labia minora.

In a short interview in the medical setting all the women reported bleeding and pain at the time of the FGM; three of the women reported that they had required medical attention. All of the women reported pain on intercourse in the months after marriage; none felt this to be related to FGM and all approved of the practice and intended to continue the tradition.

This study (3) suggested that FGM among the Bedouin of southern Israel had become a symbolic operation without the major mutilative aspect of Pharaonic circumcision or infibulation as practiced in much of Africa (1, 5). The absence of sterile techniques and the existence of genital scars still carry the risk of occasional acute medical complications or of increased susceptibility of genital transmission of AIDS (6). Moreover, the performance of a genital operation in adolescent girls must have considerable psychological impact in Bedouin culture (5).

The word “circumcision” is still commonly used among anthropologists and lay Israelis to describe the Bedouin custom of FGM. A recent press campaign in Israel assumed that the practice involves clitoridectomy, is motivated by male desire to dominate and humiliate women, and that the practice should be vigorously outlawed. Our 180

data suggested that motivation is multidetermined culturally, involves mostly female attitudes and always female perpetuators, and in Israel in 1995 was a nonmutilative operation akin to male circumcision. Physical examination as done in our study has been absent in many previous anthropological studies of FGM (4). The fact that none of our interviewed women could describe the anatomy of their own FGM suggested that cultural spokespersons and even the women themselves may be inaccurate sources of information on the nature of FGM performed in their society or even on themselves. Although there is no reason to question the vast medical and anthropological literature to the effect that cruel, mutilative FGM is widespread in Africa and Asia, specific cultures and persons that practice FGM may be involved in a very different practice that they cannot always explain.

The eradication of FGM has become critical in light of the possible role of the scars of FGM in reducing vaginal mucosal barriers to penetration of the AIDS virus (6). We suggested in 1995 that head-on abolition may be a selfdefeating approach, much as the Romans were unable to eradicate Jewish circumcision of males and achieved only revolt and Jewish martyrdom. Encouragement of evolution and sublimination of FGM from Pharaonic types, as described by Lightfoot-Klein (4), to symbolic incision of the genital area, could provide a realistic approach to this problem. Our findings among the Bedouin of Israel could provide a model. This kind of evolution may be possible, since FGM is not a religious commandment of the Koran or any other religion but only a widespread and strongly held custom.

The 2008 Follow-Up Study In the 1995 study of Asali et al. (3) six tribes were found where FGM was the norm according to anthropological interviews. However, on physical examination of women from these tribes who were having routine physical examinations for gynecological or obstetrical reasons, no instances of mutilation of the labia majora or clitoris were found. Scars were found on the prepuce of the clitoris or on the labia about 1cm in length, indicating that a ritual incision had been made but without removal of tissue, WHO classification, FGM Type IV (7). It was speculated (3) that this procedure might have been modified from an earlier original procedure that might have been more severe (8). It was suggested that the process of Westernization that the Bedouin have undergone since Israeli independence, universal health

RH Belmaker

care and compulsory education of both boys and girls might have led to a modification of the practice without a directed program towards its eradication.

In the last few years, clinicians in southern Israel have had the impression that the practice has disappeared entirely in the Bedouin population. Therefore we decided to survey again the Bedouin population with an emphasis on those tribes previously reported to perform this practice (9). Moreover, we limited our survey to women under age 30, who would have been expected to have had this procedure in the last two decades, rather than older women who might have scars from FGM performed 40-50 years ago.

Eighty percent of the interviews were done by an Arabic-speaking psychiatrist and 20% were done by an Arabic-speaking nurse. The setting of the interviews was the gynecologic clinic of a large Bedouin township or the gynecologic clinic of a smaller Bedouin township. In both township clinics, “specific tribes” that were found in the 1995 study (3) to have a high prevalence of FGM were preferentially invited to participate in the study (we do not disclose the identity of these tribes for ethical reasons.) Women coming for other services and requiring gynecological examination were asked if they would be willing to answer a few questions about their past and if they were willing to have the gynecologist, with no additional procedure, note whether any operation had been performed on their genitalia. This procedure of oral consent was approved by our Helsinki Ethics Committee (IRB). The women were sampled consecutively on days that the psychiatrist or nurse could attend clinic, but only in areas where that practice had been previously described to be prevalent. Attempts were made to interview staff and to identify times and places where women who might still be performing the practice might be available for participation in the study.

One hundred and thirty-two women were examined.

No cases of any scarring of the kind reported in the previous study (3) were found on physical examination.

Six women reported that they had heard that FGM is still going on but only by word of mouth, and we could not identify a single case that we could be referred to.

The present study (9), in combination with the study (3) published in 1995, represents an almost unique anthropological follow-up study. Few studies of this kind have been reported. Our present results strongly suggest that FGM has disappeared among the Bedouin population of southern Israel and the results are particularly striking since all of the 37 women examined

in the 1995 study had evidence of FGM. Of course, isolated incidents may still occur and any kind of mutilation can occur in the setting of psychopathology. (An example might be whether to ask if murder occurs in Paris. Of course murder occurs in Paris, but it is not the cultural norm.) One cannot rule out some continuing FGM, and indeed six women had heard that FGM still occurs. Recently, a case of severe bleeding secondary to FGM in a 16-year-old girl was reported in the Israeli Hebrew press (Maariv, June 5, 2008), the first such case at the regional hospital for southern Israel in 10 years, but the family were immigrants from Egypt and this says little about FGM in Israeli Bedouin.

What are the causes of this change? There has been no concerted program in Israel to stop FGM, although it has been discussed on television and is viewed with disapproval by the majority of the population, both Jewish and Arab. The disappearance of FGM in this population has taken place in spite of the fact that in the 1995 study (3) a large number of women said that they planned to continue this custom and would perform it on their daughters. Demographic data show that the health variables in this population, such as infant mortality and mean birth weight, and educational variables, such as percent attending school, number of school years completed and literacy, have continued to improve over the last 15 years, and these may be associated with the decline in FGM (10).

However, the practice of FGM remains prevalent in other countries, despite efforts to eliminate this practice. For example, although the government of Egypt announced that FGM is prohibited by law, a substantial number of women in that country still support this practice (11, 12). Hassanin et al. (13) reported that after six years of putting prohibition law in action, the majority of the 10-14-year-old girls (85%) in Egypt had had FGM within the last six years. Another approach has been suggested in Kenya: a substitution of FGM by “circumcision through words.” It includes one week of seclusion, when the girls are taught basic anatomy, physiology, sexual and reproductive health (14). FGM is a culturally entrenched procedure and unless a prohibition of the practice is accompanied by educational efforts, the effectiveness of legal action is low (13).

Comparison with Ethiopian Jews Christians in Ethiopia practice FGM (15), although the exact anatomic nature of their FGM has not been 181

Cultural changes and female circumcision

described (16). Jews from Arab countries where FGM is practiced do not practice FGM. However, major immigration of Jews from Ethiopia to Israel permitted study of this practice. We confirmed the report that Ethiopian Jews did practice FGM in Ethiopia (17).

Moreover, we reported the dramatic and total cessation of this custom among this community after immigration to Israel. This study of FGM is one of the few to combine anthropological interviewing techniques with physical gynecological examination. Interviews were conducted in two different absorption centers for recent Ethiopian immigrants. First we interviewed (18) six elderly women from the Tigray area and six elderly women from the Gondar area. They were considered to be good informants by social welfare staff. Two young educated translators, one from Tigray and one from Gondar, were also interviewed. One member of each group had been a professional female circumciser (Gherazit) in Ethiopia.

Interviews were conducted by a Jewish-Israeli male psychiatrist with experience in Ethiopian Jewish culture and ties to the Ethiopian community. Nevertheless, the topic was felt to be highly embarrassing and subjects were reluctant to discuss it. Coffee was served at each interview group and confidentiality was guaranteed. In addition, six men of Ethiopian origin presently working in the paramedical field in Israel were interviewed.

An experienced gynecologist examined 113 Ethiopian Jewish women in the course of routine gynecological examinations at Kupat Holim Beersheva gynecological clinic. A high-intensity lamp was used to examine the introitus and clitoris of the women.

The women’s ages ranged from 16 to 47. Only women who declared themselves Jewish from birth and who were aware of Jewish religious customs were included.

Women originated from both Tigray and Gondar.

All interviewed women agreed that FGM was normative among Jews in Ethiopia. None felt that the custom was a result of assimilation into Christianity. In Tigray the ceremony is done on Day 14 of life, in the hut where women remain after childbirth. The ceremony is performed by a special circumciser. The mother is present, as are respected female guests. Males are not allowed.

While the ceremony is not considered religious, only a Jewish woman is allowed to perform it on a Jewish infant girl. The infant is dressed in white new cloths.

The infant is held with legs spread apart, the clitoris and labial folds are held between thumb and middle finger and cut with a new disposable razor blade. The 182

Gherazit warned that the base of the clitoris is never to be injured. The amputated clitoris is removed from the room and buried. Blessings are said in the ancient Geez language holy to Ethiopian Jews, including the Biblical Ten Commandments. A feast is then eaten. The purpose of the FGM, in the view of the interviewees, is not to reduce female sexual pleasure but to create adhesions that prevent premarital intercourse.

In Gondar, the RGFS is performed on Day 7. The interviewees reported that in Gondar the clitoris is not cut but the labia minora and clitoral prepuce are removed. The removed parts are buried as in Tigray.

In Tigray the reason given for the ceremony is esthetic, since uncircumcised girls would be seen to have a “long and ugly clitoris.” Creation of adhesions is not seen as a goal of the FGM. The interviewees rationalized the absence of need for the ceremony after immigration to Israel by saying that in Israel the clitoris does not grow long for some reason.

Two educated young Jewish women of Ethiopian origin, in Israel for more than 10 years, were interviewed at length and in an individual setting without translation.

Both were aware of FGM as normative in Ethiopia, and both confirmed the above reports. Men of Ethiopian origin reported being aware of FGM among Jews in Ethiopia but knew no details.

Forty-two (37%) of the women examined had evidence of old scars. In 11 (10%) there was total amputation of the clitoris and prepuce. In 19 (17%) the clitoris was partially amputated. In 8 (7%) other women there was a 1 cm2 removal of the labia minora beneath the clitoris; in some this was bilateral and in some unilateral. In 4 (3%) women, there were scars of incision only on the clitoral prepuce, about 4 mm long. In the remaining 71 women (63%), there was no evidence of any genital past incision or ablation.

In contrast to Israeli Bedouin (3), Ethiopian Jews practiced a major form of FGM. The examinations revealed that not all women had FGM, but those who did often had major mutilation, although akin to the moderate “Sunni” rather than the most extreme “Pharaonic” type among Muslims (4). Unfortunately, no physical examination data are available on FGM among Christian Ethiopians. By contrast with the Bedouin, Ethiopian Jews give up FGM immediately on arrival in Israel. They see themselves a part of a Jewish society that does not practice FGM. No signs of distress or nostalgia for the custom were expressed. These data suggest that cultural change is often a function of identity. Rapid cultural change without evident distress may

RH Belmaker

be possible, if individuals or a group consciously accepts a new identity. An additional finding in this study, as in the Bedouin study (3), was a gap between physical findings and the anthropological report. Although FGM was normative for all Jewish female infants in Ethiopia, only about a third had evidence of old genital scars, and only 27% had clitoridectomy. This illustrates a well-known phenomenon in anthropology whereby interviews elicit descriptions of accepted norms that may reflect behavior of only a minority of individuals in practice. For instance, interviews of Israeli or American adults about marriage would yield various normative customs, although in practice divorce, out of wedlock motherhood, and adultery are commonplace. It would be interesting to discover what factors affect whether a Gherazit made a major or minor incision in practice, despite the normative custom of clitoridectomy.

This study and its predecessor (3) are among the few studies of FGM to combine anthropological interviews with physical examination (19, 20). Most knowledge of the physical nature of FGM comes from the occasional cases that reach hospital because of medical complications; these could be only the most extreme forms in the population. Our study also emphasizes the dangers of drawing conclusions from interview data only, since many women are unaware of the anatomical nature of their own FGM. Lightfoot-Klein (4) reported female orgasm among women in a culture where severe FGM is normative, but one could question whether all or even a majority of women undergo the normative operation.

Summary Our three studies taken together suggest that belief systems and group identity are the key determinants for efforts to eradicate FGM. Ethiopian Jews, who practiced a major form of FGM in Ethiopia, give up the custom upon arrival in Israel and no reports exist among pediatricians, gynecologists or the press of FGM among Jews of Ethiopian origin in Israel. Some Muslim Bedouin tribes in Israel in 1995 saw FGM as an important part of their culture, but in practice performed only a symbolic operation. By 2008 it had effectively disappeared (21).

Conflict of interest:

The author has no conflict of interest with regard to this manuscript.

Acknowledgements:

I would like to thank Dr. N. Khamaysi, Dr. S. Letzer, Dr. B. Halihal, Dr. M. Sidovsky, Dr. B. Maoz , Dr. N. Grisaru, Dr. S. Halila, Dr. Y. Abu Rabia, Dr. M. Froimovich, and Dr. J. Applebaum for active help in the studies described above.

References 1. Hosken FP. The epidemiology of female genital mutilations. Trop Doct 1978;8:150-156.

2. Female circumcision. Lancet 1983;1:569.

3. Asali A, Khamaysi N, Aburabia Y, Letzer S, Halihal B, Sadovsky M, et al.

Ritual female genital surgery among Bedouin in Israel. Arch Sex Behav 1995;24:571-575.

4. Lightfoot-Klein H. The sexual experience and marital adjustment of genitality circumcised and infibilated females in the Sudan. J Sex Res 1989;26:375-392.

5. Shaw E. Female circumcision: Perceptions of clients and caregivers. J Am Coll Health 1985;33:193-197.

6. Burton M. AIDS and female circumcision. Science 1986;231:1236.

7. WHO. Classification of female genital mutilation. 2008. http://www. who.int/reproductivehealth/topics/fgm/overview/en/index.html 8. Fourcroy JL. Customs, culture, and tradition - what role do they play in a woman’s sexuality? J Sex Med 2006;3:954-959.

9. Halila S, Belmaker RH, Abu Rabia Y, Froimovici M, Applebaum J. Disappearance of female genital mutilation from the Bedouin population of Southern Israel. J Sex Med 2009;6:70-73.

10. Belmaker I, Dukhan L, Elgrici M, Yosef Y, Shahar-Rotberg L. Reduction of vaccine-preventable communicable diseases in a Bedouin population: Summary of a community-based intervention programme. Lancet 2006;367:987-991.

11. Afifi M. Female genital mutilation in Egypt. Lancet 2007,369:1858.

12. Afifi M, von Bothmer M. Egyptian women’s attitudes and beliefs about female genital cutting and its association with childhood maltreatment.

Nurs Health Sci 2007;9:270-276.

13. Hassanin IM, Saleh R, Bedaiwy AA, Peterson RS, Bedaiwy MA. Prevalence of female genital cutting in Upper Egypt: 6 years after enforcement of prohibition law. Reprod Biomed Online 2008;16:27-31.

14. Chelala C. An alternative way to stop female genital mutilation. Lancet 1998;352:126.

15. Dagnew MB, Damena M. Traditional child health practices in communities in north-west Ethiopia. Trop Doct 1990;20:40-41.

16. Messing S. The highland plateau Amhara of Ethiopia. Philadelphia: University of Pennsylvania, 1957. dissertation available from ProQuest paper AAI0023619.

17. Harel D. Medical work among the Falashas of Ethiopia. Isr J Med Sci 1967;3:483-490.

18. Grisaru N, Lezer S, Belmaker RH. Ritual female genital surgery among Ethiopian Jews. Arch Sex Behav 1997;26:211-215.

19. Dirie MA, Lindmark G. Female circumcision in Somalia and women’s motives. Acta Obstet Gynecol Scand 1991;70:581-585.

20. El Dareer A. Attitudes of Sudanese people to the practice of female circumcision. Int J Epidemiol 1983;12:138-144.

21. Shell-Duncan B, Hernlund Y. Female circumcision in Africa. Boulder, Col.: Lynne Rienner, 2000.

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Isr J Psychiatry Relat Sci - Vol. 49 - No 3 (2012)

Attachment Patterns of Arabs and Jews in Israel Are We Really So Different?

Shiri Lavy, PhD,1 Faisal Azaiza, PhD,2 and Mario Mikulincer, PhD3 1

Ariel University Center of Samaria, Ariel University of Haifa, Haifa, Israel 3 Interdisciplinary Center Herzliya, Herzliya, Israel 2

ABSTRACT Background: Attachment orientations reflect internal representations of self, others, and relationships.

Studies revealed meaningful cultural differences in attachment orientations, but few included Arab samples. To fill this gap, we compared attachment orientations of Jews and Arabs in Israel using valid measures.

Method: Israeli participants (292 Arabs and 206 Jews) described their attachment figures and completed the Experiences in Close Relationships questionnaire which measures anxious and avoidant attachment orientations in Arabic and Hebrew, respectively.

Results: Israeli Arabs reported higher attachment anxiety than Israeli Jews, but no difference was found in avoidance. Both groups reported that attachment figures were similar in gender and relationship type, and included romantic partners, relatives and friends.

Limitations: Findings should be considered cautiously due to sampling limitations.

Conclusions: The results complement previous cross-cultural findings and Arabs-Jews differences in relationship-related norms/values. Higher attachmentanxiety scores observed among Israeli Arabs may be considered culturally normative with implications for the development of culturally competent interventions.

Address for Correspondence: shirilavy@gmail.com

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Attachment theory was first developed by Bowlby (1), in an attempt to explain psychopathologies he encountered in his counseling experiences. Bowlby focused on the importance of close relationships throughout life, and argued for their effects on behaviors, feelings and cognitive appraisals in various settings. He suggested that attachment behaviors serve an evolutionary survival need, and thus are most salient in times of stress, when humans seek proximity to a specific stronger and wiser attachment figure (1). Attachment figures serve three major functions: First, they are target of proximity maintenance as the individual seeks and enjoys their closeness and opposes to separating from them. Second, attachment figures provide a safe haven in stressful or threatening situations, since they are a source of protection and comfort. Third, they provide a secure base for exploration and development (see also 2, 3 regarding attachment in adulthood).

Furthermore, experiences with attachment figures create mental representations or “scripts” for expected patterns of interactions and relationships (what Bowlby called attachment working models; 4). These working models shape perceptions, interpretations, and responses in future interactions with others, and guide emotion regulation later in life (1). Different kinds of internal working models were categorized as different attachment styles (5, 6): If the attachment figure successfully performs the three functions mentioned above and is accessible and responsive in times of need, the individual will develop a secure attachment style characterized by trust, positive expectations of relationships, and positive appraisals of self and others.

However, when the attachment figure fails to perform the above-mentioned functions, insecure attachment will develop. One kind of attachment insecurity – anx-

Shiri Lavy, PhD, Department of Behavioral Sciences, Ariel University Center of Samaria, Ariel 40700

Shiri Lavy et al.

ious attachment – occurs when the attachment figure is intrusive or unreliable. In these cases, the individual may become clingy and over-dependent on relationship partners, and develops negative representations of the self (i.e., lower self-esteem). Anxious individuals are preoccupied about their interpersonal relationships and are afraid of rejection and abandonment.

Another kind of attachment insecurity – avoidant attachment – occurs when the attachment figure is rejecting or consistently unavailable, or when the attachment figure obsessively encourages independence. Individuals with an avoidant attachment pattern exhibit compulsive self-reliance, avoidance of intimacy in close relationships, and a general preference to do things alone (e.g., 2, 7).

A third kind of attachment insecurity – disorganized attachment – is relatively uncommon, and occurs when the attachment figure’s behavior is unpredictable and disorganized. Disorganized attachment is characterized by odd, awkward behavior and unusual fluctuations between anxiety and avoidance (8, 9).

Studies of clinical and nonclinical populations associated attachment insecurities with various psychological problems. Attachment anxiety and avoidance were related to more negative affect and depression, more psychiatric problems (e.g., suicidal tendencies, eating disorders, conduct disorders), higher rates of substance abuse and criminal behavior, and overall lower wellbeing (2, 7). Moreover, Mikulincer and Shaver (7) argued that “severe disturbances in attachment-system functioning are a key feature of most personality disorders” (p.

399), basing their claim on findings from several studies.

For example, high attachment anxiety was linked to histrionic personality disorder and borderline personality disorder, and high avoidance was associated with schizoid personality disorder and dissociative disorders (e.g., 10). Findings about disorganized attachment were even more extreme, linking this attachment pattern to several psychological problems, and generally characterizing patients with severe psychological psychopathologies (e.g., dissociative disorders and schizophrenia; 11, 12).

The attachment styles classification mentioned above (5) was empirically examined and validated in several studies (e.g., 5, 7, 8). More than a decade after the first empirical examination of attachment patterns in infancy (5), Bartholomew and Horowitz (13) developed a bi-dimensional model of attachment orientations in adulthood. According to the model they developed, attachment patterns are organized around two distinct,

continuous dimensions: attachment anxiety and attachment avoidance. Individuals who are high on attachment avoidance and low on attachment anxiety fit Ainsworth’s (5) avoidant attachment category, individuals who are high on the anxiety dimension and low on avoidance fit Ainsworth’s (5) anxious attachment classification, individuals who are low on both dimensions fit Ainsworth’s (5) secure attachment category, and individuals who have high anxiety and avoidance scores fit Main and Solomon’s (8) disorganized attachment classification.

Bartholomew and Horowitz’s (13) model was empirically validated in several studies (e.g., 14), mainly using the Relationship Questionnaire (13; a 4-item measure containing prototype descriptions of the four attachment styles of types) and the Experiences in Close Relationships questionnaire (14; a measure, which is further discussed below, comprising of two 18-items scales, one to assess attachment anxiety and the other to assess avoidant attachment). Furthermore, attachment anxiety and avoidance proved to be associated with theoretically relevant variables in the study of close relationships (e.g., self-disclosure, interpersonal conflict resolution, and relationship satisfaction) and emotions (e.g., coping with stress, emotion regulation, self-esteem, and mental health; 7).

Cultural differences in attachment orientations Most studies of attachment patterns and their correlates based their findings upon Caucasian populations in the U.S. and Europe (15, 16). However, the increasing interest in cultural and other contextual influences on attachment patterns has lead researchers to cross-culturally validate attachment theory’s basic constructs, hypotheses and scales in both adulthood (17) and childhood (18, 19). As a result, some studies have revealed cultural differences in attachment patterns and in their associations with other psychological and social constructs (e.g., 17, 20).

To date, cross-cultural comparisons of attachment patterns in adulthood suggest that secure attachment is the most prevalent and adaptive pattern in most cultures (17).

However, specific patterns of insecure attachment were especially prevalent in certain cultures, whereas other forms of insecure attachment were relatively rare. A well documented example is that people from Asian countries exhibit a more anxious attachment pattern than people from countries in other regions (i.e., North and South America, Europe, Middle East, Africa and Oceania).

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Attachment Patterns of Arabs and Jews in Israel - Are We Really So Different?

The observed differences seemed to correspond with the prevalence of specific cultural values along the collectivism-individualism dimension (19, 21). For example, meaningful associations were found between participants’ adult attachment orientations and their nation’s individualism score. Thus, participants in more collectivistic cultures reported more anxious attachment than participants in more individualistic cultures (17, 21).

In the current study, we examined attachment patterns in Israel of the Arab minority as compared to those of the Jewish majority. Although quite heterogeneous, the Israeli Arab minority has been described as a distinct national-religious-linguistic, non-assimilating and dissident minority which has not accepted Jewish-Israeli (or Western) values and norms (22). The Arab minority differs from the Jewish majority in language, religion, and other traits (23), and embraces more traditional collectivist values (22) similar to those reported in Arab countries (e.g., 24). However, recent studies show changes in their values probably due to the modernization process observed in some of their communities (25).

Yet to be explored is the way these cultural characteristics are related to attachment patterns. The few studies in Lebanon, Jordan and Morocco reported higher attachment anxiety and somewhat lower attachment security among Arabs, compared with Israelis (assumed to represent the Hebrew-speaking student samples in the Israeli colleges where they were recruited). These results conform with the expectation (empirically examined and validated by Schmitt et al., 17) that participants from countries highlighting collectivistic values (e.g., emphasizing interdependence and communality), tend to have higher ratings of attachment anxiety (reflecting hyperdependence on others and concerns about relationships).

However, the proportion of Israeli Arab participants who took part in this study (17) is unknown, making it difficult to draw clear conclusions about differences between Jews and Arabs in general, and impossible to make such inferences about Arabs and Jews in Israel.

Indeed, Israel-based studies about Arabs did not always match international data (i.e., 17). In BenAri and Malach-Pines’ (26) study of Israeli Arab and Jewish college students, no significant difference was found between the samples in attachment orientations.

However, a subsequent study (27) did reveal that secure attachment was more prevalent among Jews than Arabs (although being the most common attachment pattern in both cultures), and that both anxious and avoidant patterns were more prevalent in the Arab sample.

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The Current Study

In this study we aimed to broaden the knowledge about attachment orientations of Israeli Arabs, using valid measures and comparing them with attachment orientations of Israeli Jews. Because previous studies of Arabs’ attachment orientations typically used single-item scales to assess attachment styles (e.g., 17, 27), our first goal was to use a well-researched measure of attachment orientations. For that purpose, we translated into Arabic and ensured the internal reliability of the Experiences in Close Relationships questionnaire (ECR) (14). This is an attachment measure, comprising 36 items tapping attachment anxiety and avoidance (with lower scores on both scales indicating attachment security).

ECR has been validated in several studies (7). For this purpose, it has been translated into several languages other than English, e.g., Spanish (28), Chinese (29) French (30) and Japanese (31). Several authors claimed that adaptation of a measure developed in one culture for usage in another culture requires more than mere translation of the tool (e.g., 32-34). Such adaptation requires examination of the measure’s psychometric properties, as well as its conceptual, content and semantic equivalence (see also the International Test Commission guidelines for test adaptation) (35). The current study serve as the first step in the adaptation process of the ECR to the Israeli Arab population, using a translation process involving professionals from Jewish and Arab cultures, and providing preliminary results about the translation’s reliability after conducting first qualitative examination of its equivalence to the Hebrew version and to the American English version.

After assuring the Arabic ECR scale’s semantic equivalence and satisfactory reliabilities, we examined cultural differences in attachment orientations between Jews and Arabs living in Israel using the Hebrew and Arabic versions of the ECR. We hypothesized (Hypothesis 1) that Arabs living in Israel would report higher attachment anxiety than Israeli Jews due to their higher collectivism.

Regarding avoidance, Schmitt et al.’s (17) findings suggest no direct links between collectivism and avoidance.

The differences in avoidance levels that they revealed were linked mainly to nation-level variables related to stress and inappropriate living conditions (that predicted higher levels of all attachment insecurities). However, studies conducted in the U.S. revealed consistent, interesting gender difference in avoidance: men typically scored significantly higher in avoidant attachment than women (e.g., 14, 36, 37). These findings fit common gen-

Shiri Lavy et al.

der schemas that portray men as less emotional and less willing to connect with others (38-40). However, Schmitt et al. (41) showed that these gender differences were not universal, and were less evident in cultures with high stress. Given the complex geopolitical situation in the Middle East, we suspected that both Jews and Arabs in Israel experience elevated stress levels. Being a minority group that experiences higher poverty and unemployment rates (42), we suspected that Arabs living in Israel generally experience higher stress levels than Jews (subjected to individual differences within each population).

Thus, we expected (Hypothesis 2) small or no gender differences in avoidance in both Israeli samples, with the possibility of yet smaller gender differences in the Arab sample.

Attachment figures identity. Another goal of this study was to examine cultural variations in the identities of attachment figures. Shaver et al. (43) wrote: “the identity of the represented person, persons, or agency (e.g., mother, spouse, the Dear Leader, Allah, Jesus, Virgin Mary) will depend on cultural, political, and religious socialization.”

We hypothesized that differences in the social structure of Jewish and Arab communities in Israel would result in choosing different primary attachment figures in adulthood. Most studies on adult attachment found the romantic partner to be the principal attachment figure (for a review, see 7). This is not surprising because most of these studies have been conducted in western individualistic societies (mostly in the U.S. and Europe). In these countries, the closest familial connections are usually within the nuclear family (spouse and one’s children) and connections with the family of origin and the extended family are weaker. However, in more collectivistic and/or traditional societies, the extended family and the family of origin have a more important role in people’s daily lives (44, 45). Thus, we hypothesized (Hypothesis 3) that Jews would nominate their romantic partners as their principal attachment figure more often than Arabs, whereas Arabs would be more likely to nominate members of their extended family.

to 48 (M = 24.3, SD = 4.7); and n= 292 Arabs, 66% were women, ranging in age from 19 to 38 (M = 26.2, SD = 4.7). Over 95% of the Israeli Arab participants were married, compared with 14% of the Israeli Jews (although 65.7% of the latter reported having a significant, meaningful relationship at the time of the study). This difference in marital status may result from the cultural differences in the normative marriage age, which is lower in the Arab sub-culture compared with that of secular Jews (secular Jews comprised 79.9% of this study’s Jewish sample). To identify marital status effects, all analyses were conducted first on the entire samples, and then only on married participants (in the two samples) (Table 1).

Table 1. Demographic Characteristics of Arab and Jewish Samples Israeli Arabs n=292

Israeli Jews n=206

Involved in a significant meaningful relationship

95.6%

65.7%

Married

95.6%

14%

Relationship duration

45.65 months*

42.40 months*

Have children

50.2%

7%

Occupation

36.4% Students 33.3% Teachers 4.2% Secretaries 3% Lawyers 3% Accountants 2.3% Engineers 2.3% Salespersons 15.5% Other occupations (doctors, managers, psychologists, housewives, social workers, pharmacists, electricians, etc.)

69.3% Students 4.8% Soldiers 3.2% Managers 3.2% Salespersons 2.6% Secretaries 22.3% Other occupations (teachers, lab technicians, instructors, waitresses, engineers, etc.)

Religion

77.7% Muslims 22% Christians 0.30% Druze

79.9 % Secular Jews 20.1 % Religious Jews

Ancestors

Method Participants

Participants were recruited in public places (such as academic campuses) in northern and central Israel and in personal gatherings/meetings (i.e., snowball sample). The participants were recruited by research assistants from the same cultural background. Participants included, n=206 Jews, 78% were women, ranging in age from 19

29% Ashkenazi Jews 20.5% Mizrahi Jews 15.1% Moroccan Jews 10.8% Ethiopian Jews 7.5% Mixed origins 6.5% Russian Jews 10.6% Other (Yemenite, North African, Iraqi, Hungarian, Asian Jews).

*excluding participants who were not involved in a meaningful relationship at the time of the study.

187

Attachment Patterns of Arabs and Jews in Israel - Are We Really So Different?

Measures

Experiences in Close Relationships questionnaire (ECR) (14) was used to assess attachment orientations. This questionnaire includes two 18-item scales, one measuring attachment anxiety (e.g., “I worry about being abandoned”) and the other measuring avoidance (e.g., “I prefer not to show a relationship partner how I feel deep down”). Participants rate the extent to which each item describes them in close relationships, using a 7-point scale ranging from 1 (not at all) to 7 (very much). The scale was translated from English into Hebrew by Mikulincer and Florian (46), who also demonstrated the measure’s intended two-factor structure in Israeli samples.

In this study, the ECR scale was translated into Arabic (see Appendix 1). To the best of our knowledge, this is the first published Arabic translation of the ECR. The translation and adaptation process included a few steps, in an attempt to address some of the methodological concerns of adaptations (e.g., 32, 34, 47). The 36 ECR items were first translated from Hebrew into Arabic by a bilingual psychology Israeli scholar, and back-translated by a bilingual MA student. This back-translated version was compared with the original version, and minor revisions were made (while consulting with bilingual experts from the field). This process was lead by an Israeli Arab social work professor, to promote cultural relevance and equivalence of the tool, its instructions and its items (following Alegria et al.’s [32] and Kirmayer and Young’s [48] recommendations, although the need for generalizability of the results limited the revisions of items). Pilot data were collected using the revised form in a small student sample, which also provided qualitative feedback.

Following this feedback, changes were made, and the final form was used to collect the data reported here.

Coefficient alphas for the two attachment scales were satisfactory in both samples, for the 18 attachment anxiety

items were .88 and .84, and .78 and .74 for the 18 avoidance items in the Jewish and Arab samples, respectively.

Final scores were calculated for each scale by averaging participants’ responses on the various items in each scale.

The scores of the two scales were only modestly correlated (as intended) in the Jewish sample, r = .13, p = .05, and in the Arab sample, r = -.08. Therefore they were treated as separate independent variables in the analysis.

Attachment figure identity was assessed using a question taken from the WHOTO scale (3) which identified a person’s primary attachment figures: Please write the first name of a person who supports you and accepts you as you are. A person that you feel calm and comfortable in his presence, and you know you can count on him/her whenever you need. Then participants were asked to provide information about the attachment figure’s gender, the nature of his/her relationship with the participant, and the relationship duration. Demographic questions (e.g., participants’ age, gender, relationship duration with the attachment figure) were included in the last page of the questionnaire.

Procedure

Participants completed the questionnaires voluntarily.

After their anonymity was assured and their consent for participation was received, participants completed the questionnaires in their native language. The protocol of the research project follows the guidelines of Ariel Center’s ethics committee and conforms to the provisions of the Declaration of Helsinki.

Results Attachment Orientations

Means and standard deviations of attachment orientations among Arab and Jewish men and women are presented in Table 2.

Table 2. Means and Standard Deviations of Attachment Scores of Arabs and Jews by Gender

All participants Anxiety Avoidance Participants in meaningful relationships Anxiety Avoidance

188

Men

Arabs Women

Total

Men

Jews Women

Total

3.96 .91 3.47 .72

3.86 .99 3.29 .76

3.91 .95 3.35 .75

3.52 .75 3.52 .75

3.59 .97 3.39 .77

3.56 1.00 3.42 .77

3.93 .93 3.45 .75

3.85 .97 3.27 .76

3.88 .96 3.32 .76

3.48 1.06 3.47 .78

3.53 .92 3.33 .75

3.51 .95 3.37 .75

Shiri Lavy et al.

Table 3. Results of MANCOVA examining culture and gender differences in attachment orientations (anxiety and avoidance), with age and relationship duration covariants for entire sample (n = 498)

MANCOVA Wilks’ λ F Partial Eta Squared Post-Hoc ANOVAs -Anxiety F Partial Eta Squared -Avoidance F Partial Eta Squared

Age

Relationship Duration

Culture

Gender

Culture x Gender

.98* 4.13* .02

.98* 3.51* .02

.97** 6.56** .03

.997 .64 .003

.996 .94 .004

3.68 .01

.09 .00

12.48*** .03

.75 .002

1.87 .004

4.70* .01

6.92** .02

.76 .002

.52 .001

.03 .00

* p < .05; ** p < .01; *** p < .001

Table 4. Results of MANCOVA examining culture and gender differences in attachment orientations (anxiety and avoidance), with age and relationship duration covariants- including only participant in a meaningful romantic relationship (n=304)

MANCOVA Wilks’ λ F Partial Eta Squared Post-Hoc ANOVAs -Anxiety F Partial Eta Squared -Avoidance F Partial Eta Squared

Age

Relationship duration

Culture

Gender

Culture x Gender

.98 2.84 .02

.99 1.12 .01

.97** 5.80** .03

.996 .71 .004

.996 .70 .004

4.09* .01

.07 .00

11.48*** .03

.80 .00

1.38 .00

1.85 .005

2.02 .006

.29 .00

.55 .00

.04 .00

** p < .01; *** p < .001

To eliminate artifacts, when examining cultural and gender differences in attachment orientations, we controlled for age and relationship duration. We conducted a two-way MANCOVA with attachment orientations (anxiety and avoidance) as dependent variables. Culture and gender were entered as independent variables, and age and relationship duration served as covariates. The relationship duration of participants who were not involved in a meaningful romantic relationship at the time of the study was 0. Participants who did not indicate whether or not they were involved in a meaningful relationship were not included in the analysis.

The MANCOVA (Table 3) revealed significant effects of the covariants age (Wilks’ λ = .98, F [2, 449] = 4.128, p = .02) and relationship duration (Wilks’ λ = .98, F [2, 449] = 3.51, p = .02) on the combined dependent variable. In order to investigate the detailed effects of the covariants,

four univariate F-tests were performed, indicating that both age and relationship duration were significantly related to avoidance, but not to anxiety (Table 3).

After adjusting for the effects of the covariants, the MANCOVA revealed a significant main effect of culture on the combined dependent variable (Wilks’ λ = .97, F [2, 449] = 6.56, p = .03). The effect of gender and of the interaction between gender and culture were not significant. Post-hoc ANOVAs showed that Arabs’ anxiety ratings (but not avoidance ratings) were significantly higher than among Jews (Tables 2 and 3).

A similar MANCOVA (with the same covariants and dependent and independent variables) was conducted only for participants who reported being in a meaningful romantic relationship at the time of the study (Table 4). In this MANCOVA age and relationship duration had no significant effects on the combined dependent 189

Attachment Patterns of Arabs and Jews in Israel - Are We Really So Different?

variable. However, subsequent post-hoc ANOVAs conducted separately for anxiety and for avoidance revealed a significant effect of age on attachment anxiety (Table 4).

Similar to the results of the first MANCOVA, the results of the second MANCOVA also indicated a significant main effect of culture (Wilks’ λ = .97, F [2, 359] = 5.80, p < .001). Post-hoc ANOVAs’ results indicated that the source of this effect was significant differences between Arabs’ and Jews’ anxiety ratings (Tables 2 and 4).

Attachment figure

The attachment figure most frequently reported by Jews (43.8%) and by Arabs (60.1%) was the romantic partner, while a minority of Jews (21.1%) and Arabs (18.3%) reported a same-sex friend as their primary attachment figure. Fewer participants nominated their mothers (8.8% and 6.4% of the Jewish and Arab participants, respectively); a member of their extended family (6.7% and 3.2% of Jews and Arabs, respectively); their sister (6.2% and 3.2% of Jews and Arabs, respectively); their brother (3.1% and 4.1% of Jews and Arabs, respectively); or their father (2.6% and 2.3% of Jews and Arabs, respectively).

Few participants also mentioned a friend from the opposite sex (5.2% and 2.3% of Jews and Arabs, respectively); or an ex-romantic partner (1.5% of Jews).

Group differences in attachment figure’s identity were significant (c2[10, N = 412] = 19.15, p < .05), and remained significant when relationships were grouped by familial relationships, romantic relationships, and friendships (c2[2, N = 410] = 8.48, p = .01). Although romantic partners were the most frequently nominated attachment figures in both groups, Jewish participants were more likely than Arab participants to nominate members of their family of origin or friends as their principal attachment figure. Arabs tended to nominate their romantic partners as their attachment figures even more than Jews did.

When the analysis was conducted only for married participants in both samples, the differences between the samples in attachment figure’s identity were nonsignificant. Furthermore, although non-significant, differences in the married subsample were in line with our hypotheses: Jews were more likely to nominate their spouse as their attachment figure (70.4% of married Jews) than Arabs (60% of married Arabs). In this subsample, Arabs were more likely to nominate a relative (20%) or a friend (20%) as an attachment figure than Jews (14.8% for both relatives and friends).

A similar analysis conducted again only on participants (married and unmarried) who reported being 190

involved in a meaningful relationship, yielded similar results, with yet smaller differences between the samples: 63.4% of the Jews nominated their romantic partner as their attachment figure; 20.3%, a relative; and 16.3%, a friend. Among Arabs, 60% nominated their romantic partner; 20.5%, a relative; and 19.5%, a friend.

Discussion The study goal was to broaden our knowledge about attachment orientations of Arabs in Israel and compare them to those of Jews in Israel, while using a valid quantitative tool (the ECR questionnaire). Findings generally supported our hypotheses, but also included surprising similarities in the identities of attachment figures Attachment orientations

As expected, attachment anxiety was higher among Israeli Arabs than Jews. This difference may be related to group differences in collectivism values, which is assumed to be higher among the more traditional, family-oriented Arab sample (e.g., 22).

As expected, there were no gender differences in avoidant attachment, in both samples. These findings correspond with Schmitt et al.’s (17) results implying small or no gender differences in avoidance in cultural regions with high stress levels.

Attachment figures

Examination of attachment figures’ identities yielded interesting results. Surprisingly, small and non-significant cultural differences were noted between Arabs and Jews in the identities of attachment figures: the most frequently nominated attachment figure in both cultures was a romantic partner. Also, relatives and friends were often nominated as attachment figures in both cultures. About one-third of married participants and more than half of the single participants nominated a relative or a friend as their attachment figure.

These findings highlight cultural similarities between Israeli Arabs and Jews (see also 26). It seems that Arab and Jewish participants were similar in their utilization of romantic partners and best friends as primary sources of support in times of emotional distress. This similarity may be related to behavioral and cultural norms in Western societies, in which the newly developed family (and not the family of origin) provides the daily, stable social needs of people. However, the close connections with friends may be related to social norms in Israel (e.g.,

‫‪Shiri Lavy et al.‬‬

‫‪and collectivism, both Arab and Jewish communities‬‬ ‫‪in Israel are considered to be more collectivistic than‬‬ ‫‪other Western societies, i.e., the U.S. (23, 24), and their‬‬ ‫‪members are thought to have stronger social and famil‬‬‫‪ial networks (e.g., 22, 25) compared with Americans.‬‬ ‫‪Developing attachment relationships with relatives‬‬ ‫‪or members of the social network may be foreseeable‬‬

‫‪the value and normative duration of friendships) or to‬‬ ‫‪the specific samples (i.e., young adults).‬‬ ‫)‪Our findings also broaden Hazan and Shaver’s (2‬‬ ‫‪assertion, later adopted by numerous attachment‬‬ ‫‪researchers and clinicians (see 7, 49), that the primary‬‬ ‫‪attachment figure in adulthood is one’s romantic part‬‬‫‪ner. Although differing in their level of traditionalism‬‬

‫‪Appendix 1: Experiences in Close Relationships Questionnaire - Arabic Translation‬‬

‫تطرق الجمل التالية إىل الشكل الذي تشعر\ين به داخل منظومة العالقات القريبة التي تقيمها \ تقيمينها مع أشخاص آخرين‪ .‬يقصد بالكلامت “أشخاص آخرين” الواردة يف الجمل التالية‬ ‫باألشخاص الذين يقيمون معك عالقات قريبة‪ .‬يرتكز اهتاممنا حول كيفية شعورك‪ ,‬عامة‪ ,‬داخل هذه املنظومة من العالقات‪ .‬أرش\ أشريي إىل مدى موافقتك أو عدم موافقتك إىل ما يرد يف الجمل‬ ‫التالية من خالل استخدام سلم التدريج التايل‪:‬‬ ‫ال أوافق عليها بتاتا‬ ‫أوافق جدًا‬ ‫‪7‬‬

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‫ّ‬ ‫أفضل أن ال اظهر شعوري الداخيل لألشخاص اآلخرين‬ ‫أخىش أن يبتعدوا عني وان اترك وحيدًا‬ ‫اشعر براحة حني أكون قري ًبا\ة من األشخاص اآلخرين‬ ‫أخىش من منظومة العالقات التي أقيمها‬ ‫ابتعد حني يبدأ األشخاص اآلخرون االقرتاب مني‬ ‫أخىش من أن يكون اهتامم األشخاص اآلخرين يب ليس مبقدار اهتاممي بهم‬ ‫ال اشعر براحة حني يرغب األشخاص اآلخرون االقرتاب مني‬ ‫أخىش من فقدان األشخاص القريبني مني‬ ‫ال اشعر براحة حني أتعامل بانفتاح مع أشخاص آخرين‬ ‫أود أن يكون شعور األشخاص اآلخرين نحوي قو ًيا مثل شعوري نحوهم‬ ‫أود االقرتاب من األشخاص اآلخرين لكنني ال أزال ابتعد عنهم‬ ‫أود أحيا ًنا االختالط بشكل مطلق مع األشخاص اآلخرين األمر الذي يبعدهم عني أحيا ًنا‬ ‫اشعر بالتوتر حني يقرتب األشخاص اآلخرون مني أكرث مام يجب‬ ‫أخىش من أن أكون وحيدًا‬ ‫اشعر براحة حني أشاطر األشخاص اآلخرين التفكري واألحاسيس الخاصة‬ ‫رغبتي يف أن أكون قريبا تبعد اآلخرين عني أحيا ًنا‬ ‫أحاول أن امتنع من االقرتاب من األشخاص اآلخرين أكرث مام يجب‬ ‫احتج إىل الكثري من التأكيدات عىل أ ّنني محبوب من األشخاص القريبني مني‬ ‫اشعر بسهولة نسبية لالقرتاب من األشخاص اآلخرين‬ ‫اشعر أحيا ًنا بأ ّنني اجرب األشخاص اآلخرين عىل إبداء األحاسيس وااللتزام بشكل اكرب‬ ‫ً‬ ‫مرتبطا باألشخاص اآلخرين‬ ‫اشعر بصعوبة حني أكون‬ ‫يف كثري من األحيان ال اشعر بقلق من أ ّنني ساترك وحيدًا‬ ‫ّ‬ ‫أفضل أن ال أكون قري ًبا من األشخاص اآلخرين أكرث مام يجب‬ ‫حني ال انجح يف إثارة اهتامم األشخاص اآلخرين يب اشعر بالغضب واإلحباط‬ ‫أخرب األشخاص القريبني مني بكل يشء‬ ‫اشعر بأن األشخاص اآلخرين ال يرغبون االقرتاب كام أريد‬ ‫عادة أناقش مشكاليت واهتاممايت مع األشخاص القريبني مني‬ ‫حني ال أكون جز ًءا من منظومة عالقات أشعر باضطراب وعدم ثقة بشكل ما‬ ‫ً‬ ‫مرتبطا بأشخاص آخرين‬ ‫أشعر براحة حني أكون‬ ‫ً‬ ‫محبطا حني ال يتواجد اآلخرون معي كام أريد‬ ‫أصبح‬ ‫ال أتردد يف أن أتوجه إىل اآلخرين لطلب املواساة‪ ,‬النصيحة أو املساعدة‬ ‫اشعر باإلحباط حني أكون بحاجة لآلخرين وال أجدهم‬ ‫يشكل التوجه لآلخرين حني أكون بحاجة لهم دعماً يل‬ ‫حني ال مينحني اآلخرون تأكيدًا أشعر سيئًا للغاية إزاء نفيس‬ ‫أتوجه لألشخاص اآلخرين بأمور كثرية مبا يف ذلك املواساة والتأكيد‬ ‫حني يقيض األشخاص القريبون مني وقتًا طوي ًال بعيدًا عني‪ ,‬هذا األمر يثري معارضتي‬

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Attachment Patterns of Arabs and Jews in Israel - Are We Really So Different?

outcomes of these social characteristics, which are less prevalent in other Western societies.

The current findings also bear implications for the use of ECR in relational studies, suggesting its relevance to attachment figures other than romantic partners.

ior should not be considered abnormal or strange. As a result, when exploring and developing patients’ support systems in treatment, clinicians should refer to a broader range of figures (beyond romantic partners), especially relatives and friends.

Limitations

References

This study’s results are based on self-reports of nonrepresentative convenience samples of Israeli Arabs and Jews, differing in certain demographic characteristics (e.g., marital status). As such, they are subjected to social desirability and interpretation biases and one should be cautious in generalizing the current findings before replicating them in other samples. Furthermore, the assessed differences between Arabs and Jews are based on participants’ ethnic affiliations, and not on their cultural orientations. Such inference about the nature of individuals from their group’s characteristics (ecological fallacy) neglects individual differences within cultures, which can be substantial in heterogenic subcultures.

This study also lacks information about the ways other psychological constructs (e.g., high-order personality traits) and psychological outcomes (e.g., wellbeing) are related to cultural differences in attachment orientations and attachment figure’s identity. These have yet to be explored.

Conclusions and implications

Our findings generally complement previous cross-cultural findings linking prevalence of attachment patterns to social and cultural contexts (e.g., 15, 17). More specifically, they support the use of the ECR scale for assessing attachment orientations among Arabs in Israel, and provide evidence for differences between Arabs and Jews in attachment orientations and similarities between these two groups in attachment figures’ identities.

The findings described above should be considered in the clinical care of Arabs and Jews in Israel. Arabs’ higher attachment anxiety should be considered in the therapeutic context, bearing in mind that the higher anxiety scores may reflect social processes reinforcing interdependence, and that it may have adaptive advantages in Arab society. Interventions should also be developed to fit expectations and behaviors of people with higher attachment-anxiety scores.

The results regarding attachment figures suggest that a notable proportion of the Israeli population (both Arabs and Jews) turns to people other than their romantic partner in times of need, and that such behav192

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Isr J Psychiatry Relat Sci - Vol. 49 - No 3 (2012)

The Role of Sociocultural Information in Mental Health Intake Sessions Margarita Alegría, PhD,1 Arlene Katz, PhD,2 Rachel Zack Ishikawa, MPH,3 Yaminette Diaz-Linhart, MSW,4 Anne Valentine, MPH,5 and Sheri Lapatin, MIA5 1

Center for Multicultural Mental Health Research, Cambridge Health Alliance, Somerville, MA, and Harvard Medical School, Boston, MA, USA Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA 3 Clark University Psychology Department, Clark University, Worcester, MA, USA 4 Boston Medical Center, Boston University School of Medicine, Boston, MA, USA 5 Center for Multicultural Mental Health Research, Cambridge Health Alliance, Somerville, MA, USA 2

The authors have no conflict of interests to declare.

ABSTRACT Background: Clinicians are advised to provide culturally competent care but little is known about how this directive translates into clinical practice. We investigated how this directive was implemented by describing how clinicians utilize sociocultural (SC) information, and how it impacts the clinical encounter.

Method: Data were collected in clinics in the Northeast of the U.S. Clients (N=129) and clinicians (N=47) participated in three components of the study: videotaping of the clinical intake, a qualitative interview, and reporting on sociodemographics. Thematic analysis of interviews was conducted using NVivo7.

Results: Clinicians used sociocultural information to understand clients’ clinical presentation; inform diagnosis; differentiate psychopathology from contextual circumstances that influence behavior; create empathy; and individuate clients.

Limitations: Since the study only included data from public clinics, the results may not generalize to other settings.

Conclusions: Integrating SC information appears critical to client engagement and to bonding between client and clinician, particularly for diverse populations utilizing public clinics.

Funding/Support: The Patient-Provider Encounter Study data used in this analysis was provided by the Advanced Center for Latino and Mental Health Systems Research of the Center for Multicultural Mental Health Research at the Cambridge Health Alliance. This study was supported by the National Institutes of Health (NIH) research grant #1P50MHO73469 and was funded by the National Institute of Mental Health (NIMH), and by UPR-CHA Research Center of Excellence: Making a Difference for Latino Health, research grant #P60MD002261, funded by the National Institute on Minority Health and Health Disparities (NIMHD).

Introduction The cultural competency movement seeks to help clinicians and mental health organizations meet the needs of a diverse client population (1, 2) by improving their understanding and appreciation of cultural differences. Advocates maintain that culturally competent mental health care may lead to more effective care (3-5) and ameliorate health care disparities (2).

Clinicians are advised to consider the social and cultural factors that contribute to their clients’ clinical presentation (6), but little is known about how such directives translate into clinical practice. This study aims to answer two related questions: For what purpose do clinicians collect sociocultural (SC) information in the intake interview? And how does this information impact the clinical encounter?

Address for Correspondence: Margarita Alegría, PhD, Department of Psychiatry, Harvard Medical School and Cambridge Health Alliance, 120 Beacon St., 4th Floor, Somerville, MA, USA 02143 malegria@charesearch.org

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Background Multiple efforts to define and disseminate guidelines for culturally competent mental health care in clinical training programs (7) and practice have been made in the last 20 years (8). The Multicultural Counseling Competencies (9) maintain that clinicians require basic knowledge, awareness, and skills (10), a conceptualization that has also been endorsed in the development of more recent frameworks (e.g., 11-14). The American Psychiatric Association’s guidelines for cultural formulation advise clinicians to supplement their multiaxial diagnostic assessments with investigation of the cultural aspects of the client’s identity and to explore how culture influences diagnosis and care (6, 15).

The role that guidelines play in practice is unclear.

Inconsistencies between clinicians’ beliefs about the importance of addressing diversity issues and what actually transpires in psychotherapy have been noted (16). Moreover, it has been suggested that some clinicians may question the therapeutic value and/or appropriateness of addressing sociocultural differences with their clients (17). Research examining cultural competency in health care is in its infancy. Methodological limitations abound; yet, early empirical studies are promising, particularly with respect to patient engagement and retention in care (18). Given the scant evidence to support how culturally competent care improves service outcomes, particularly mental health outcomes, clinicians may be uncertain how to put culturally competent care into practice (17, 19).

Nevertheless, a growing body of evidence suggests the importance of addressing diversity issues in psychotherapy as a way to enhance the therapeutic relationship (20) and to accomplish treatment goals (21).

Acknowledging the complexity of culture and ethnic/ racial identity may result in more accurate diagnosis and treatment (e.g., 12, 22, 23). In particular, clinicianled exploration of trauma with political violence survivors has demonstrated that deliberately attending to trauma helps promote therapeutic goals (24).

Given the critical role of the intake interview in discerning a client’s clinical and social situation and treatment goals (20), our study focuses on this session. We posit that demands of the intake (e.g., establishing rapport, preliminary diagnosis, and treatment planning) may increase if there are intercultural client-clinician differences, given potential added challenges such as cultural/language variance and resultant difficulties in

interpretation of symptom probes (21, 25). This augments the likelihood of diagnostic bias among racial and ethnic minority clients (25). The extent to which these demands are affected by clinician-led exploration of patient SC information is poorly understood.

Research examining racial-ethnic matching among clinicians and clients as a means of enhancing therapeutic alliance and improving outcomes (e.g., dropout rate, length of treatment, client functioning) has resulted in inconsistent findings (26, 27). Still, the degree of clinicians’ cultural sensitivity may be related to greater client self-disclosure (28), suggesting that process variables such as clinician competence, awareness and commitment to diversity issues in therapy is an important area of inquiry (19, 26, 29).

This study offers insight about how clinicians utilize SC information and how discussion of SC information can influence the client-clinician communication. To our knowledge, this is one of the few studies examining such a process in naturalistic settings, to suggest how it may be used by clinicians in cross-cultural mental health care.

Methods Data were collected in eight safety-net outpatient clinics in the Northeast U.S. offering mental health and substance treatment services to a diverse client population. See Alegría et al. (25) for a complete description of study protocol. A convenience sample of 47 clinicians (CN) participating in mental health intakes was recruited through introductory informational meetings.

The majority were female (66%), predominantly 35-49 years of age (45%), and permanent staff (68%) with more than five years of clinical practice (70%). Twentysix percent were psychologists; 28% were psychiatrists; 38% were social workers; and 18% were nurses.

Approximately 53% of clinicians self-identified as nonLatino whites, while 36% self-identified as Latino, 9% as non-Latino black (African-American or AfricanCaribbean), and 2% as Asian.

The majority of the 129 clients (PT) were recruited through direct person-to-person solicitation at intake sessions. Of them, 60% were female; 50% were Latino; 39% were non-Latino white, and the remaining 12%, African-American or African-Caribbean. Nearly twothirds of the sample (65%) completed high school and 45% were employed. Approximately 64% reported a personal income of less than U.S. $15,000 per year, 195

The Role of Sociocultural Information in Mental Health Intake Sessions

and approximately 50% were on Medicaid, the state financed insurance for low income individuals. Data collection complied with human subject protocols at participating clinics and at Cambridge Health Alliance in Somerville, Massachusetts.

Both clients and clinicians participated in three separate components of the study: 1) videotaping of the intake; 2) a post-intake qualitative interview conducted immediately after the session; and 3) completion of sociodemographic and clinical measures. Clinician interviews included questions regarding their understanding of the client’s presenting problem, the process of clinical decision-making, perceived rapport, and the role of SC factors in the client’s presenting problem.

Client interviews included questions about the presenting problem, perceived rapport, and significance of SC factors in the presenting problem. All interviews were conducted by trained research assistants blind to the goals, constructs, and hypotheses of the current study.

Qualitative Analysis

Thematic analysis of the clinician (CN) and client (PT) interviews was conducted using NVivo 7 (30). Analysis procedures followed recommendations by Braun and Clarke (31) for using the full study sample. First, an a-priori codebook was developed, which included eight predetermined conceptual categories based on the study aims. These categories represented “buckets,” in so far as they contained general rather than specific themes.

The buckets were based on reviews of the literature about mental health intakes, the goals of the study, and questions included in the semi-structured post intake interviews (e.g., clinician decision-making, perceived rapport and references to SC factors).

For this study, 30 case-examples from the original 129 cases were initially selected from the larger Patient Provider Encounter Study (PPES). Half of these cases were racially/ethnically concordant client-clinician dyads and half were racially/ethnically discordant client-clinician dyads to distinguish whether the information collected varied across the two types of dyads.

Both matched (n=15) and non-matched (n=15) dyads included 5 Latino, 5 non-Latino white, and 5 black clients each. Cases chosen for the 30 case-examples were selected if either the clinician or client referred to culture, race, ethnicity or religion, and social factors, including age, gender, and social class. Two primary research questions guided the initial analysis of the 30 case-examples: what information gets collected and 196

how it influences the diagnostic intake process. Coders read the excerpts included in each bucket first, and then organized selected references into sub-categories. Postintake transcripts were coded by three members of the team to establish reliability and organized under the aforementioned categories. Coders met weekly. When disagreement arose, the research team attempted to identify the source of the discrepancy and coded sections were reviewed again until consensus was reached (24, 32). To examine how using SC data influenced the interactional process between clinician and client in more detail, the research team reviewed in depth four cases from the 30 case-examples. The cases selected included both clinician and client reference to SC factors as playing a specific role in the clinical intake. The cases varied based on ethnic/racial match, with three matches: Latino clinician (CN) /Latino client (PT), black CN/ black PT, Latino CN/Latino PT, and one non-match: white CN/Latino PT. The research team analyzed full transcripts of clinician (CN) and client (PT) post-diagnostic interviews and viewed the tape of the intake session. Data sources were triangulated, systematically comparing and contrasting post-diagnostic interviews of clinicians and clients.

Results How did clinicians use sociocultural information?

To individuate clients, clinicians asked about a range of SC factors including, but not limited to country of origin, cultural background, experiences of discrimination/racism, ethnicity, family history, immigration history, political factors, religion/spirituality, and trauma.

We identified three primary ways in which clinicians use SC information in the intake: 1) to create empathy; 2) to individuate clients; and 3) to understand clinical presentation, inform diagnosis, and enable differentiating psychopathology from contextual circumstances that might influence behavior. Using SC information allowed clinicians to see clients as unique persons and to visualize what matters most to them.

We present the following examples illustrating clinicians’ use of SC information in trying to make sense of who the client is as a person, separate from clients’ diagnosis and/or clinical presentation. Clinicians described how understanding a client’s SC context was instrumental to relational engagement and served as means to create a bond: Latino clinician (101CN) referring to a Latino client:

Margarita Alegría et al.

“So what really made me feel very connected with him was that, the fact that he’s a very young guy, an immigrant, and fatherless.”

Black clinician (312CN) recounting experience with non-Latino white client: “… She’s working, she needs a babysitter … . That’s when I had to try to make decisions as well … I could be hard-nosed, ‘this is the program you gotta go with it and you just get a babysitter,’ or looking at her as a person who is really striving to do better, can I more or less assist her and kind of work with her? And I felt that was my choice, to work with her.”

Non-Latino white clinician (301CN) referring to a non-Latino white client: “Um, she indicated a RomanCatholic background as far as her church … . I think it’s important to be able to get some idea of their religious background and current level of spiritual involvement in order to … utilize that as part of their recovery process.”

One clinician (305CN) eloquently explained that he explores SC information more explicitly with clients of the same ethnicity or race to avoid the impression that he is making assumptions about them, or that they in turn make assumptions about him.

Black clinician (305CN) referring to intake process: “When I’m intaking, let’s say an African-American person, male or female, I find it just might be a little bit more difficult … they have another African American here in front of them … so they try to impress me or even call me brother or ‘you know what I mean,’ ‘you know where I’m coming from.’ And I’ll say, ‘No, I don’t know where you’re coming from’ … So this way I feel with, uh, let’s say with a Caucasian, male or female, it’s, they know that I don’t know where they are coming from so now I’m asking. So it’s more, ‘I’m trying to learn something.’ So they’re kind of teaching me, um, ‘Hey, my culture is about this, this is what we do, this is my religion.’”

Familiarity with certain cultural norms, clinical manifestations, or language helped clinicians understand clients’ clinical presentation (105CN) and contextualize their experience in order to better understand what they perceived as normal or abnormal (106CN, 115CN), why their symptoms might present in a certain way, or assign a particular degree of severity (118CN). SC information helped guide case formulations and treatment ideas. SC information that several clinicians identified as important for influencing their perception of clinical presentation included client’s ethnicity (115CN, 408CN), socioeconomic status (106CN, 309CN), political trauma (106CN), immigration status (118CN, 423CN), and family context (309CN). Clinicians also described how SC

factors informed their diagnosis, sometimes (208CN, 420CN) serving to rule out a diagnosis, because the SC context presented justified behavior that could otherwise be seen as pathological.

The following clinician narratives illustrate this theme: Latino clinician (105CN) referring to her Latina client: “’An oppression in my chest …’ is a typical way of how they [Latinos] describe anxiety; she also says that she suffers from a lot of headaches and that’s very common in Latina women who are depressed.”

Latino clinician (118CN) describing his Latino client: “He was living in a situation where you had to be hypervigilant so it was partly adaptive … . So, again, in terms of why post-traumatic stress disorder, yes he’s had various exposures to violent situations and of extreme fear and he had comrades or whatever or fellow soldiers that died and he saw people that had experienced ambushes … . Yet, he doesn’t sound like he had sort of acting out behaviors in terms to manage affect because of his traumatic experience …”

Black clinician (208CN) recounting experience with her black client: “I did ask her, ‘despite all of this, how is your faith’ … . I forget exactly how she put it, but um, kind of, ‘God walking by her side throughout this entire time and that he’s still there’ and … […] Well, I, I viewed that as one of the supports that is very helpful to her in managing her symptoms. Um, rather than um, looking at, looking at it as a sign of pathology.”

The extent to which clinicians explicitly acknowledge the importance of SC factors in case conceptualization and diagnosis varied greatly within our sample. For some clinicians, SC factors were addressed in a technical, categorical manner to establish the client’s preference for language or to gain information about race, ethnicity, education, and socioeconomic factors. Some clinicians adamantly stated that client SC information did not influence the diagnostic process while others were careful to clarify that even though they make culture-free diagnoses, they do not dismiss cultural information altogether, as it helps in understanding the client’s circumstances.

Still others maintained that the link between diagnosis and SC information was situational; some diagnoses had nothing to do with culture, while others depended on examining cultural beliefs or experiences (e.g., what is seen as normal physical abuse in spousal relations) to be properly diagnosed (102CN). Trauma information was particularly salient in linking SC and diagnosis (101CN, 208CN). For example, clinicians stated being more likely 197

The Role of Sociocultural Information in Mental Health Intake Sessions

to assign a diagnosis of depression than anxiety in clients with a history of trauma.

Sociocultural information’s influence on clinician/client interaction Transcript passages in each bucket revealed several themes linked to how discussion of SC information influenced the client-clinician interaction during the intake. This included: 1) engagement via mutual understanding and rapport building; 2) enhanced clinical appraisal of the client; 3) clinician self-reflection; and 4) differential diagnoses, including differentiation of symptoms from everyday hardship. To explore how use of SC information influenced the interaction between clinician and client, we next examined four cases in which both the clinician and client cited the importance of SC information as part of the intake process.

In the first case, an African American client gives a touching account of the traumatic shift in her life circumstances. She cries as she describes her transition from being a professional to becoming homeless.

Client (208PT ): “It’s like my life is completely governed by a system that’s outside of my reach. I can’t see my children but once a week … I haven’t lost custody …

I don’t have them as a result of the depression, the anxiety - I was very paranoid about everything, I was very delusional about things. I just was not in control.”

Rather than initially following up on social factors, the clinician follows her protocol, clarifying past medical history. In response, the client continues to elaborate on the shift in her status. When the clinician acknowledges her suffering and picks up on the importance of her faith, the clinician’s understanding of what was significant for the client deepens.

Clinician (208CN):”[Y]ou never imagined you’d be on the other side. How was your faith?” Client (208PT): “It’s very helpful because it, like, gives me this understanding that God is present even in what I’m presently dealing with.”

Focusing on spirituality was also critical for the clinician to clarify the client’s potential psychotic symptoms and ultimately, ruling out a schizophrenia diagnosis. Rather than looking at her spirituality “as a sign of pathology,” the clinician began to see it as a support to overcome adversity. Yet, when asked about the importance of the client’s social, racial, and cultural background, this clinician dismisses its influence in the patient’s diagnosis. Her primary focus, she maintains, is on “the facts of her symptoms.”

In this second case, a Latina clinician (CN105) inter198

twines SC issues throughout the interview and addresses how SC factors affect engagement with her Latina client. The clinician (105) uses SC factors to get to know her patient as an individual. She demonstrates being a “cultural insider,” emphasizing words and phrases her patient uses to describe her symptoms. When asked about the use of SC factors, this clinician narrates asking the patient’s ethnicity, race, and culture and discussing social and contextual factor as a way to deepen their relationship. In the post diagnostic interview, the clinician feels moved to a stance of advocacy through concern for her client who works in a windowless factory.

Clinician (105CN): “She’s worked for 18 years in the factory. I mean, it’s horrible working there. I believe her.

She says at the factory …. she doesn’t speak English … so when the alarm goes off she only thinks, ‘I don’t want to burn inside.’ She can’t even understand if they’re telling her something. … That’s hard, that’s very hard … that factory … has no windows.”

In the post diagnostic interview, this client echoes this sense of engagement. (105PT):” … she understood me very well. There is no doubt … She understood me and made me feel good …”

In this third case, a Latino client (101PT) describes how he came to the emergency department of the hospital having difficulty breathing, palpitations and feeling fearful about his health. What he was experiencing was diagnosed as an “ataque de nervios” (a nervous crisis, an idiom of distress) and he was referred to mental health care. The Latino clinician reviewed the emergency department clinician’s diagnosis, which was not the client’s explanation for what has brought him to the clinic. The client was most “preoccupied with his health” to determine “if I have some physical problem.”

The tension between what matters most to the client (his physical health) and the clinician’s agenda of exploring in detail the “ataque de nervios” (a nervous crisis) is noticeable in the diagnostic interview. As the clinician transitions to engage the client by asking him about his immigration experience, he feels a real connection, and is struck by the client’s loneliness, resulting in a diagnosis of depression.

Clinician (101CN): “… This is an immigrant, so that was the first kind of connection. For me, he is 18 but … like, for me[he] is a child, I mean he’s a young adult, but I felt like a big brother or like a father, an immigrant very alone here.”

In the post diagnostic interview, the client did acknowledge that the clinician “explained things well”

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and felt connected to him, saying “we had good chemistry,” because the clinician understood his experience in the U.S. In the diagnostic intake of this fourth case, a Latina client narrates her shift in life circumstances since her diagnosis of diabetes, and her fear that she will share the same fate as her father, who lost a leg to the disease. Once an active, energetic person, she now “wants to be alone.” The non-Latino white clinician (712CN) empathizes that “it is a new experience for you,” which is echoed by the client. Although she acknowledges her depression, her main reason for coming to care was diabetes, which her doctor said “needs to be seen with depression.” When asked what helped inform his diagnosis, the clinician cites the client’s age and culture, and provides a description of how the client’s culture influenced him.

Clinician (712CN): “….[h]er coming from a Latino culture where, uh, it’s patriarchal, and females have less of a role in making money for the family. It’s more accepted for a female to be within the house and taking care of things within the house … . Her role in the house, um, I think, represents the potential for, um, a depressive experience.”

Discussion Our results clarify the primary uses of SC information in the intake interview: to create empathy; to individuate clients; and to understand clinical presentation so as to inform diagnosis; and differentiate psychopathology from contextual circumstances that might influence behavior. These functions underscore the importance of client SC information in service delivery. Differences between the clinician and client may be surmounted by asking about SC factors. As Lakes et al. recommended for clinicians (22), the integration of the client’s perspective with the clinician’s observations may allow clinicians to entertain the world of their clients. Cardemil and Battle (33) suggested that: “a willingness to engage clients in these (SC) dialogues can promote an environment of trust and understanding that will ultimately help the treatment process” (33, p. 278).

Yet our findings also demonstrate how cultural information can act as a double-edged sword; leading to stereotypes and missed opportunities to explore what most matters to the client (24). Our fourth case of Clinician 712 illustrates how assumptions and stereotyping (e.g., gender roles) can increase the risk of over interpreting SC factors, influencing diagnosis and

treatment approaches. In this case, not acknowledging what was most important to this client (“her diabetes”) was a missed opportunity to explore the traumatic aspects of the illness. The clinician instead bases his diagnosis partly on generalized cultural stereotypes, attributing the client’s depression to her being a middle aged, Latino woman having difficulty doing the housework, keeping her role in that “patriarchal” culture.

This is consistent with past literature that has shown that cultural judgments can bias clinicians toward both exaggerating and minimizing psychopathology (34-36), but can also help clinicians understand the subtleties of clinical presentation (23, 37).

Our results also evidence great variance in how clinicians apply this information to their case conceptualizations and diagnoses. Contrary to the findings of Hansen et al. (38), most clinicians did not acknowledge the importance of (SC) factors, but many did introduce multicultural counseling competencies (including knowledge, awareness and skills) into practice. Clinicians demonstrated these competencies: they asked questions about SC factors, discussed ethnicity/race and national origin, assumed differences (even if ethnic/racially matched), adapted clinical inquiry to the client’s SC history, avoided assumptions, allowed clients to self-define, and minimized the opportunities for hasty diagnoses.

These differences might be due to the types of safetynet clinics included in our study which emphasized culture and context. Adaptations made by these clinics included strategies for enhancing clinic cultural competence, such as adaptation of client materials to Spanish, Haitian Creole and other languages, hiring of non-white staff, and diversity training for clinic staff and clinicians (39). Different results could be evidenced in mainstream clinics in private settings. This represents a limitation of the current study and emphasizes the importance of collecting information in different organizational environments.

Our case presentations also demonstrate how SC factors shape the clinical encounter in a reciprocal manner (40). In certain examples (Client 1) it allowed for cultural brokering, supporting a client amidst adversity and/or sudden shifts in client sense of self. In other cases (Clients 2 and 3) cultural knowledge enhanced the interpretation of what was at stake for the client, creating greater engagement. We see elements of the use of SC information as a supportive tool in the identification of spirituality in Client 1. Lopez and Guarnaccia (41) suggested the importance of identifying such protective factors in the client’s environ199

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ment. In all of these cases, integrating an inquiry of SC factors created a shared narrative between clinician and client. Lakes et al. (22), drawing on Mattingly and Lawlor (42) discussed the development of a ‘shared narrative’ in which client and clinician create meaning about how culture affects the client’s life. This narrative is also implicated in culturally-relevant planning for future clinical encounters. We can envision that over the course of treatment this narrative is actually a dynamic one that will change and evolve (22). Just as cultural information may help inform an accurate diagnosis in the initial evaluation, it can influence the course of work with a given client, by providing an “accurate” and shared cultural narrative that is a starting point for ongoing shared planning for treatment.

Given the great variance in how clinicians translated culturally-competent principles, institutions could provide reflective and practical experiences in applying culturally competent care. These approaches might include multicultural supervision (43) and structured education around the principles of multiculturalism (44, 45), beyond teachings of a graduate degree. Additional training efforts could include experiential learning techniques through continuing education (46) and self-assessment tools (47) that facilitate clinician reflection and awareness. Another strategy could promote the creation of organizational guidelines that encourage eliciting and understanding of client cultural practices, family history, language, involvement with host country, context as well as cultural explanations of the client’s illness, psychosocial functioning and help-seeking behavior (48).

Conclusion Our four case studies show a mix of sociocultural, physical, and psychological elements addressed by clinician and client to further their understanding and co-construct their care agenda. Our results emphasize how this is a critically important area of focus that affects diagnosis and treatment for multicultural clients and should be an area of ongoing study. It is important to include in practice those structures that can facilitate construction of shared stories to improve client engagement and sense of understanding and prospectively evaluate whether it has an impact in the outcomes of care.

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An overview of findings, together with methodological and conceptual issues. Cultur Divers Ethnic Minor Psychol 2005;11:113-129.

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28. Fuertes JF, Bartolomeo M, Nichols CM. Future research on counselor multicultural competencies. J Multicult Couns Devel 2001;29:3-12.

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32. Hill CE, Knox S, Thompson BJ, Williams EN, Hess SA, Ladany N. Consensual qualitative research: An update. J Couns Psychol 2005;52:196-195.

33. Cardemil EV, Battle CL. Guess who’s coming to therapy? Getting comfortable with conversations about race and ethnicity in psychotherapy. Prof Psychol Res Pr 2003;34:278-286.

34. López SR. Patient variable biases in clinical judgment: Conceptual overview and methodological considerations. Psychol Bull 1989;106:184-203.

35. Comas-Díaz L. The future of psychotherapy with ethnic minorities.

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36. Pinderhughes E. Understanding race, ethnicity, and power: The key to efficacy in clinical practice. New York, N.Y.: Simon and Schuster, 1989.

37. Guarnaccia P, Pincay I, Shrout P, Alegría M, Lewis-Fernandez R, Canino G. Assessing diversity among Latinos: Results from the NLAAS. Hisp J Behav Sci 2007;29:510-534.

38. Hansen ND, Randazzo KV, Schwartz A, Marshall M, Kalis D, Frazier R, et al. Do we practice what we preach? An exploratory survey of multicultural psychotherapy competencies. Prof Psychol Res Pr 2006;37:66-74.

39. Paez KA, Allen JK, Carson KA, Cooper LA. Provider and clinic cultural competence in a primary care setting. Soc Sci Med 2008;66:1204-1216.

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42. Mattingly C, Lawlor M. The fragility of healing. Am Anthropol 2001;29: 3057.

43. Garrett MT, Borders LDA, Crutchfield LB, Torres-Rivera E, Brotherton D, Curtis R. Multicultural superVISION: A paradigm of cultural responsiveness for supervisors. J Multicult Couns Devel 2001;29:147-158 44. Preli R, Bernard JM. Making multiculturalism relevant for majority culture graduate students. J Marital Fam Ther 1993;19:5-16.

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Isr J Psychiatry Relat Sci - Vol. 49 - No 3 (2012)

The Effect of Social Identities of Service-Users and Clinicians on Mental Health Disparities: A Review of Theory and Facts Ora Nakash, PhD,1 Tamar Saguy, PhD,1 and Itzhak Levav, MD2 1 2

School of Psychology, Interdisciplinary Center (IDC), Herzliya, Israel Ministry of Health, Jerusalem, Israel and Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel

ABSTRACT Mental health disparities are differences in health status, risks and care favoring members of advantaged over disadvantaged social groups. The contrasting social identities of clinicians and service-users may account for potential disparities found in clinical encounters, reflected, for example, in the provision of substandard care. The imputed mechanisms, however, remain unknown. Drawing on social psychological research we delineate a model to assist in identifying those mechanisms. We review the literature on processes rooted in social categorization (outgroup bias) and in social power (impaired perspective taking, making automatic attributions) and suggest that the contrasting social identities of clinicians and service-users can partially account for why discordant, compared to concordant ethnic identities in clinical encounters may produce worse outcomes, measured by the quality of the working alliance and the accuracy of diagnostic decisions. We provide preliminary evidence for the proposed model and submit a research agenda to inform evidence-based interventions to counter the negative outcomes of discordant encounters.

Health disparities are defined as unequal health status, risks and care favoring members of advantaged over disadvantaged social groups in society (1). Social advantage or disadvantage refers to the relatively favorable or unfavorable socio-demographic (e.g., gender, Address for Correspondence: onakash@idc.ac.il

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ethnicity) economic or political conditions that some groups systematically experience based on their relative position in society (2). For example, in the United States, whites have lower prevalence rates of psychiatric disorders than other ethnic groups in the country, even when potential confounding variables, e.g., socioeconomic status, are controlled (3). Similar findings have been documented in other countries with national health insurance systems, such as Israel and the United Kingdom (4, 5).

Recent studies in Israel show that prevalence rates of mental health disorders are higher among Israeli Arabs, who constitute 20% of the population and are relatively disadvantaged, as compared to Israeli Jews (4). Consistent differences in mental health also exist between immigrants from the former Soviet Union and the Israel-born majority (6), as well as between Mizrahim (Jews of Asian/North African descent) and Ashkenazim (Jews of European/American descent).

For example, the prevalence rates of mood and anxiety disorders are approximately twice higher for second generation Mizrahim compared with their Ashkenazi counterparts (7). In accordance with the Convention on the Rights of Persons with Disability (8), these inequalities call for remedial action for those seeking psychiatric care guided by research such as that purported to identify the mechanisms involved in the clinical encounter.

In this paper we review relevant literature from social psychological research and present initial evidence proposing that processes rooted in social categorization and in social power may in part contribute to mental health disparities in the clinic. More specifically, we explore potential mechanisms that may mediate the

Ora Nakash, School of Psychology, Interdisciplinary Center (IDC) Herzliya, P.O.Box 167, Herzliya 46150, Israel.

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relationship between the social identities of clinicians and service-users and the course and outcomes of the clinical encounter.

The effect of social identities of service-users and clinicians in the clinical encounter on health disparities

Although differences in genetic susceptibility to disease contribute to differences in health status (e.g., Huntington’s disease is most prevalent among people of European ancestry whereas sickle cell anemia most commonly affects people of Mediterranean ancestry; 9, 10), the role played by social factors in the development and persistence of health disparities has been solidly documented (2, 5). Social causation models attribute poor mental health status to adversity and stress among socially disadvantaged groups (11, 12). For example, lower socioeconomic status is associated with limited access to health care (2) and to lower rates of health literacy frequently associated with higher prevalence rates of different psychiatric disorders (13). Other research provided support for the role of perceived discrimination as a significant social stressor that mediates the association between disadvantaged ethnic groups and mental ill-health (14).

Beyond the impact of those macro (or distal) factors, such as genetic and social influences, an additional set of micro (or proximal) factors, such as those arising from the clinical encounter, have been identified as potential contributors to health service disparities (15, 16). This set of factors, which is the focus of the current paper, pivots around elements in the service userclinician interaction that have the potential to influence the course and outcome of the clinical encounter. At the core of this set of factors lies the notion raised by the 2002 U.S. Institute of Medicine’s report: “…when faced with patients who are from different racial or ethnic backgrounds, doctors may find that their uncertainty about the patient’s condition and best course of treatment is even greater. This uncertainty can ‘open the door’ for physicians’ stereotypes and biases to affect their judgment of patients and interpretation of their presenting concerns” (1). The report suggested that clinicians from advantaged groups in the U.S. (e.g., a white physician) may provide care of inferior quality to members of disadvantaged groups (i.e., racial and ethnic minorities), due to psychological biases triggered by differences in their respective social identities. Thus, clinical encounters between clinicians from an advan-

taged group (the vast majority of cases in Western countries; 17) and service-users from disadvantaged groups may involve different psychosocial processes resulting in different outcomes than those between equal ethnic dyads.

Studies conducted primarily in the U.S. and the U.K. support the above suggestion (for a review, see 16). For example, primary care doctors rated African American patients as less intelligent, less educated, more likely to abuse drugs and alcohol, more likely to fail to comply with medical advice, more likely to lack social support, and less likely to participate in cardiac rehabilitation than white patients, even after patients’ income, education, and personality character­istics were taken into account (18). Similarly, other studies showed that white physicians were less patient-centered (19), engaged in less joint decision-making (20), and had shorter encounters (21) when interacting with African American than with white patients. Also, both British and U.S. psychiatrists were more likely to prescribe antipsychotic medications, use involuntary admission, and place patients in seclusion once hospitalized, when treating non-white relative to white patients, independent of appropriateness and clinical factors (22, 23).

It is thus not surprising that African American patients show higher premature dropout rates when treated by a white clinician than by an African American clinician (24), and were found to perceive white clinicians as less credible than African American clinicians (25). African American patients tended to be more satisfied with the medical encounter and their care when their physician was African American than when their physician was white (26). They also had a general preference for African American clinicians (27). Taken together, the accumulating evidence suggests that the concordant or discordant social identities of serviceusers and clinicians may relate to the course and outcomes of the clinical interaction.

Effects of social identities on clinical outcomes: Data from the Israeli context

Although health disparities have been studied in Israel for over half a century (28) and gained growing attention in recent years (29), little work has examined the effect of ethnic identities on the outcomes of the clinical encounter. To investigate this topic, we conducted two studies focusing on the Mizrahi-Ashkenazi intergroup context.

Although the common perception is that differences in power and status between Ashkenazim and Mizrahim are 203

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long gone (30), consistent evidence from both the Central Bureau of Statistics and health studies (7, 31-33) document that inequality between the groups are still apparent in levels of education, average income and health status.

All these indicators favor the Ashkenazim. Beyond these objective measures of resources, Saguy et al. (34) demonstrated that psychological processes characterizing minimal groups (laboratory groups formed based on a random criterion) of either high and low power replicated fully among Ashkenazim and Mizrahim. (e.g., Ashkenazim were less supportive of egalitarian social policies than Mizrahim). Similarly, Levin and Sidanius (35) found that the same responses Israeli Jews had toward Israeli Arabs (a socially disadvantaged group) in terms of affect and resistance to change replicated among Ashkenazim with regard to the Mizrahim. Thus, both structural and psychological aspects of power associated with social identities characterize the relations between Ashkenazim and Mizrahim, providing a suitable context for the study of the effect of processes related to those identities on health care.

In the studies we conducted we investigated whether a Mizrahi compared with an Ashkenazi alleged patient elicits different evaluations of therapeutic alliance by Ashkenazi participants. Items were extracted from the Working Alliance Inventory which has been widely used to assess quality of patient-clinician relationship in different settings, including single-session-encounters (36). Study I was conducted among a sample of psychology students (N=48; Mage=26.33, 71% female) and Study II was conducted among a group of practicing mental health clinicians recruited through snow-ball sampling (N=20; Mage=39.90, 80% female). Each participant read a vignette of a patient presenting depressive symptoms and then rated the extent to which the alleged patient is expected to be cooperative in treatment on five different items (e.g.,“to what extent would he cooperate with treatment?”; Cronbach’s a=.88 in Study I, a=.82 in Study II). Responses to these items were given on a 1 (not at all) to 10 (very much) scale. In each study, we manipulated the name of the patient to sound either Ashkenazi (Shtern) or Mizrahi (Abutbul).

Consistent with our hypotheses, Study I revealed that psychology students of Ashkenazi descent expected a Mizrahi alleged patient to be significantly less cooperative in treatment (Mean=6.4, SD=1.8) compared to an Ashkenazi alleged patient (Mean=7.7, S D=1.0), t(46)= 3.09 p<.01, Cohen’s d=0.88. Importantly, the finding replicated among mental health clinicians in Study II, 204

providing a large effect size, Mean = 6.7 (SD=1.3) vs.

Mean=8.1 (SD =.8 ), t(18)= -2.88 p=.01, Cohen’s d= 1.33.

These results demonstrated that despite their equidistant role as clinicians, the ethnic identity of an alleged patient led Ashkenazi clinicians to respond less favorably to a patient from a Mizrahi descent and to rate him as less cooperative. Thus, these local findings agree with the U.S. Institute of Medicine’s report (1) arguing that processes rooted in biases on the part of clinicians may contribute to health disparities among those who seek help.

Notwithstanding this emerging focus on the clinical processes rooted in social identities, the mechanisms contributing to their influence on health care remain unclear. What exactly happens when a clinician from a certain ethnicity meets a patient from a different ethnicity? Why is this interaction different from the one between a clinician and a patient who share the same ethnicity? Does the status associated with the ethnicity matter? Would a clinician from an advantaged group who treats a patient from a disadvantaged group be more biased than a clinician from a disadvantaged group who treats a patient from an advantaged group?

Our initial studies do not allow us to answer these questions (as we only considered clinicians from an advantaged ethnicity and patients from a disadvantaged ethnicity), they provide us with an essential starting point which documents that group membership matters in clinical encounters. Our next step is to develop a theory that would help identify the different processes which may contribute to the biases rooted in group membership.

Such a theory would then set the stage for new studies which could identify specific mechanisms, and different identity structures, as predicting outcomes of the clinical encounter. Identifying those mechanisms is crucial for informing evidence-based interventions aimed at countering the processes contributing to the negative course and possible outcomes of discordant encounters.

A model to account for potential mechanisms

Our proposed model suggests potential mechanisms that may mediate the relationship between the social identities of clinicians and service-users and course and outcomes of the clinical encounter drawing on social psychological research. We begin by reviewing relevant literature on social categorization and the role it might play in clinical encounters. We then turn to review psychological processes related to power differences arising from contrasting status, and consider how those might play a role in the service user-clinician interaction. We

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chose to focus on social categorization in particular because, as prominent social psychologists have argued over the years (38-40), it stands at the root of encounters between people belonging to different social groups and can therefore serve as a fertile ground for understanding processes characterizing discordant clinical encounters.

The issue of power is one such process, deriving from social categorization. In addition, although here we focus on ethnic social identities we acknowledge that similar processes may play a role also in concordant and discordant clinical encounters based on other social identities such as gender (41) and socioeconomic status (42).

Social categorization and health disparities

Social categorization shapes and perpetuates intergroup biases. Just as people categorize objects, so too, they categorize each other into ingroups (the groups containing the self) and outgroups (the groups not containing the self) (39, 40). This tendency to categorize people into “us” and “them” is both rapid and automatic, and has important implications for the way people think, feel and behave toward group members. Importantly, research has documented an automatic favoritism for the ingroup over the outgroup (39). For example, in the U.S., white participants are found to be faster in associating whites, over African Americans, with positive valence (for a review, see 43).

People were also found to experience more positive affect toward their ingroup over outgroup members (44); to help ingroup members more (45); to expect ingroup members to be trustworthy (46); and share one’s attitudes and values more than outgroup members (47).

Several social psychological theories attempt to account for these findings, such as people’s limited cognitive capacities, which often lead to reliance on heuristics, or mental short-cuts, e.g., stereotypes (48, 49), that confirms pre-existing views of the in- or outgroup.

Structural theories argue that competitive relations between groups, and associated threats, lead to negative outgroup perceptions (e.g., Realistic Group Conflict theory; 50, 51, and Group Position models; 52, 53).

Social identity theory (54), suggests that individuals derive an important part of their self-concept, including their social identity, from their group membership.

Because social identity bears directly on one’s selfdefinition, people are generally motivated to enhance or protect the value attached to their group. This need can be easily satisfied by comparing one’s own group to others, in a way that would reflect a positive value for the ingroup and devalue the outgroup (“we are better

than them”). An example of intergroup comparison that can reflect positively on one social identity is when a person with a chronic mental disorder is devalued and stigmatized by a person who has no disorder (e.g., 55).

Although limited, recent literature links biases associated with social categorization to quality of health services (56-59). In particular, implicit bias, which refers to unconscious negative feelings and attitudes that operate automatically during social interactions (60), was found to influence the way clinicians approach service-users belonging to outgroups (18, 61). For example, Green et al. (62) measured U.S. physicians’ explicit and implicit attitudes toward African American alleged patients.

They found that when presented with vignettes about patients with symptoms of myocardial infarction, physicians higher in implicit bias were less likely to recommend appropriate drugs for African American patients compared with white patients.

Thus, processes of categorization and associated intergroup biases, which are prevalent in a variety of contexts, also take place in the health field, in cases of discordant clinical encounters (see also 16, 63). Beyond the above-cited processes of outgroup biases, clinical encounters are also characterized by asymmetrical social power, as discussed next.

Social power and health disparities

Social power, defined as the ability to influence the outcomes of others through control over material (e.g., money) or social (e.g., knowledge) resources, has been shown to impact human behavior (64-66) . Any service user-clinician interaction is by definition hierarchical, because the latter holds both the knowledge and expertise (67). However, in identity-discordant encounters, another layer of power is added, namely, power by virtue of group membership (34, 53). This layer adds to the already existing amount of power-by-social-role, resulting in a clinician from an advantaged group having overall more social power in discordant encounters.

Whereas researchers in the area of health disparities have identified the problems arising in discordant encounters (18-23), little attention has been given to the specific psychological processes associated with social power. We hypothesize that the greater amount of clinician’s social power in discordant encounters which parallels societal power (i.e., a clinician from an advantaged group and a patient from a disadvantaged group) can lead to worse health care compared with concordant encounters. Two processes that characterize power-hold205

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ers and are particularly relevant to the clinical encounter are hypothesized to account for these effects: impaired perspective taking and tendency to perform automatic rather than complex attributions.

Research on power and perspective taking, the ability to step outside of one’s own experience and imagine the emotions and perceptions of others (68), demonstrates that the psychological experience of power can impair perspective taking. Galinsky et al. (66) found a negative correlation between people’s sense of power in social relationships (a measure that correlates with occupation of powerful social roles) and their tendency to adopt the psychological point of view of others, which can affect empathic ability. Similarly, participants primed with an experience of power (compared to a neutral experience) were less accurate in detecting others’ emotions (cf. 69).

In another experiment in which participants were given a supervisor role over an outgroup member, perspective taking was lower compared to a control condition (70).

In clinical encounters, the ability to take the patient’s perspective is considered crucial and stands at the core of the therapeutic alliance (71, 72). Yet, clinicians were shown to vary in the degree in which they include patients’ perspective in medical decisions (73), and some have suggested that this ability is particularly impaired in discordant encounters (74). Building on the work demonstrating impaired perspective taking among high power individuals, we suggest that clinicians who experience a greater sense of social power in clinical encounters might be less able to take their patients’ perspective. Such impaired perspective taking can in turn undermine the clinician’s perception of the patient as cooperative and pleasant – factors that underlie the quality of working alliance which we have shown to be undermined in discordant encounters. Thus, we propose that the power differences that exist between a clinician from an advantaged group and a patient from a disadvantaged group might hinder the clinician’s ability to take the perspective of the patient, which in turn can result in worse therapeutic alliance.

A second process that we propose might impact the quality of the clinical encounter relates to the effects of power on the way people interpret others’ behavior, namely, their tendency to make automatic rather than complex attributions. Automatic attributions are relatively rapid, effortless, and associated with the use of cognitive heuristics and simple rules to make judgments (75, 76), usually resulting in dispositional inferences of behavior which rely on stereotypes and pre-existing schemas (77). In contrast to automatic inferences, complex 206

attributions involve more deliberate considerations of situational constraints (78). Pettigrew (79) has shown that group membership plays a significant role in attribution processes. People tend to attribute negative behaviors of outgroup members to inherent dispositions whereas negative behaviors of ingroup members are attributed to more situational factors. Social power was further shown to moderate this tendency such that members of advantaged, relative to disadvantaged groups, were found to be more likely to make more dispositional attributions to negative actions of outgroup members (80). These results are in line with work showing that power holders are prone to make automatic judgments and discount complex stereotypically-inconsistent information about others’ behavior (e.g., 77, 81).

We suggest that the tendency of power holders to make less complex attributions may characterize clinicians in identity discordant clinical encounters, and can ultimately lead to worse diagnostic decisions. Because psychiatric diagnostic decisions rely heavily on the way clinicians collect (information variance; 82) and weigh the information presented by service-users (decision variance), attribution complexity can significantly impact diagnostic decisions. Although as of now we do not have direct evidence from the local context about diagnostic decisions in discordant encounters, research conducted in the US supports the notion that discordant encounters may result in worse diagnostic decisions (see 16 for a review). For example, Alegria et al.

(83) found that even with similar information collected during the intake, mental health clinicians weighed the information differently to assign a diagnosis depending on service-users’ ethnicity. Specifically, U.S. Hispanics, who during their intake raised issues of family history of abuse, were more likely to be given depression diagnosis than non-Hispanic whites who raised similar information. Thus, diagnostic decisions seem to be impacted by the identity of the patient, yet the processes contributing to this effect remain unexplored. Our proposition is that differences in the tendency to make complex attribution may account for this effect.

Finally, if our proposed hypotheses on the impact of power associated with advantaged group membership on the way clinicians think and behave in clinical encounters are accurate, then such processes should be particularly pronounced among those committed to their ethnic group (an Ashkenazi clinician who strongly identifies himself/herself as Ashkenazi). Extensive social psychological research demonstrates that people who are

Ora Nakash et al.

strongly committed to their groups show greater levels of group-based biases (84, 85). Thus, clinicians highly identified with their advantaged group may be more motivated to reaffirm their group’s power (86, 87).

Individual variables pertaining to service-users are also likely to play a role in this interactional context.

For example, a Mizrahi service-user might be more or less identified as such, and, as a result, elicit different responses from an Ashkenazi clinician. Recent research in the area of group identity demonstrates that members of advantaged groups indeed detect level of identification of outgroup members, even given minimal information such as facial features (88) and react more negatively to high, compared with low identifiers (89).

Although more infrequent in public care, discordant identities that reverse societal power dynamics between groups (e.g., a Mizrahi clinician and an Ashkenazi service-user) are also of interest. Such clinical encounters may result in better outcomes than concordant encounters because power differences are more balanced.

Another contrasting possibility, however, is that the disadvantaged group status of the clinician will debilitate clinical decision-making through processes of behavioral inhibition (65). Although we cannot make ad hoc predictions regarding discordant encounters in which societal power dynamics are reversed, these encounters are worthy of exploration.

Recommendations for future research In this paper we suggested that processes rooted in social categorization and in social power may contribute to mental health disparities in the clinic. We propose that these processes should become part of a research agenda aimed at better understanding the course and outcome of clinical encounters. In addition, individual-level variables (i.e., level of implicit and explicit bias, level of ethnic identification) need to be incorporated into the research design and methodology.

Both experimental designs in which the social identities of alleged service-users will be manipulated and field studies in which real-life concordant and discordant interactions are studies can help illuminate the causal links between the different factors we proposed.

For example, an experiment conducted among practicing mental health clinicians can test whether the social identity of their patients impacts the clinician’s appraisal of the quality of the working alliance (via the mediation of perspective taking) and their accuracy of diagnostic

decisions (via the mediation of attribution complexity).

An alleged patient’s social identity can be manipulated through the presentation of a videotaped clinical vignette in which an analogue service-user (either advantaged or disadvantaged) would present a multifaceted clinical problem (including details identifying ethnic origin, level of identification, psychiatric symptoms, and stressors).

Clinicians would be randomly assigned to view either an advantaged or disadvantaged service-user who is either high or low in ethnic identification. Accuracy of diagnostic decisions and quality of reported alliance by clinicians can serve as indicators of the quality of the clinical interaction. Similar field studies, though would not allow us to test causal links, can provide external validity to suggested links in the model.

Another form of laboratory study can be designed to further investigate whether it is the difference in identity per se that produces biased orientations, or the differences in status and power which accompany it. In such a study, one can independently manipulate the identity of an alleged patient to be of different ethnicity, but one time with higher status and another time with a lower status. For example, one can choose a sample of Mizrahi providers and have them encounter an Ashkenazi alleged patient in one condition (a different group, advantaged patient) and an Ethiopian alleged patient in another condition (a different group, disadvantaged patient). In such design, both conditions involve an outgroup patient, but each time the status of the patient’s ethnicity is different. Indeed, such a design would complement the initial studies we conducted, in which it is difficult to determine whether it is the differences in social identities, or differences in status, which produced the effect.

Future studies should also include indicators of attribution complexity, which were missing from our pilot investigation. For example, clinicians can be presented with a list of factors that could account for the patient symptoms (e.g., situational factors, ability, family history, mood problem), and be asked to assign a weight to each factor, based on how strongly they think it accounts for the patient’s symptoms. Attribution complexity can be assessed by the magnitude of the variability among weights assigned to the different factors, such that less variability (i.e., considering more factors as equally important) would indicate more complex attributions (90, 91) After specifying the processes by which discordant social identities hinder the course and outcomes of clinical encounters, the proposed research agenda can further 207

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inform evidence-based interventions aimed at ameliorating such processes. Extensive social psychological research has identified both individual-level factors and contextual influences, which impact processes of intergroup biases.

This body of work can be effectively used to develop relevant interventions in the clinical encounters. For example, a substantial amount of research, dating back to the classic work of Gordon Allport (40) on the contact hypothesis, has established that positive intergroup interactions (i.e. those involving equal status, cooperation, potential for personal acquaintance, and institutional support) can lead members of advantaged groups to hold more positive and less biased attitudes toward members of disadvantaged groups. Over the past 60 years, both researchers and practitioners have relied on contact theory in attempts to ameliorate the detrimental consequences of intergroup biases (see 92 for a meta-analysis summarizing over 515 studies). This work further examined the effects of different types of interaction “contents,” ranging from encounters which solely focus on cross-group commonalities to those emphasizing diversity (93, 94). An example for an application that can be relevant to our purposes is work done by Rudman et al. (95), in which students have undergone a diversity training seminar taught by a minority instructor.

These students showed a significant decrease in implicit and explicit indicators of prejudice, relative to students who were taught neutral content by the same instructor or were taught neutral content by an instructor from the majority group. Such “unlearning” of group-based biases can be applied to the mental health field by offering special diversity training programs to clinicians, taught by disadvantaged group members.

Evidence-based interventions can be further developed to target the specific processes of impaired perspective taking and automatic reasoning. For example, building on studies which identified ways to increase perspective taking, clinicians can be asked to write an essay from the perspective of a patient from a disadvantaged group and emphasis will be placed on imagining the other person’s feelings (96). This type of intervention can be also incorporated into diversity training sessions, which could be specifically designed to target clinicians from advantaged groups. Along the same lines, clinicians can be further taught and trained to improve their attribution style to be more complex when encountering minority patients. Such interventions should take into consideration individual-level factors likely to further influence people’s general tendency to make biased judgments when encountering 208

outgroup members. Such factors include people’s general orientations toward hierarchy (as reflected by their Social Dominance Orientation; 97), their political attitudes (98) , and also structural factors such as income and education level (99, 100).

Acknowledgements

This study was supported by Marie Curie Reintegration Grant funded by the European Union (#IRG231007 to Nakash) and the Israel National Institute for Health Policy and Health Services Research (2006/6/‫ א‬to Nakash).

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Isr J Psychiatry Relat Sci - Vol. 49 - No 3 (2012)

Psycho-Social Reactions of Palestinian Families in Israel and the West Bank Following War-related Losses Khawla Abu-Baker, PhD (LMFT) The Max Stern Academic College of Emek Yezreel, Israel and Al-Qasemi Academy – Academic College for Education, Baka Al Garbeia, Israel

ABSTRACT Objective: To identify psycho-social reactions of Palestinian families to personal losses during the Second Intifada in the West Bank and the Second Lebanese War in Israel.

Method: Narratives were collected from support group participants in the West Bank and in individual and family therapy in Israel. The narratives were qualitatively analyzed to identify themes relating to psycho-social reactions to war losses.

Results: Themes emerging from the West Bank support groups’ narratives mostly mirrored those gathered in the therapy sessions in Israel. In both sites, bereaved families exhibited similar psycho-social reactions to war-related losses. Both groups coped with loss collectively and in congruence with their common ethno-cultural background. Also, religious beliefs provided explanations. The loss experiences were ongoing and accumulative for participants in the West Bank, while in Israel it was mostly a single event.

Limitations: Both studies referred solely to warrelated losses.

Conclusions: The relationships of each population group with the State of Israel shaped their political, national and personal reactions to the loss. Families of “shahids/ martyrs” in the West Bank gained socio-political respect, while in Israel, Arab citizens suffering warrelated losses did not receive the same political respect

Address for Correspondence:

from Israeli society, but were awarded sympathy by their communities. In Israel the situation is further complicated since the State is both the enemy and provider of material support, comfort and rescue.

Introduction War is a traumatic event that causes psychological, physical, familial, and social damage and changes in daily life routine (1-5). In Israel, most, but not all, wars have been fought beyond its borders. The Second Lebanese War (SLW) was an exception, since missiles fired from Lebanon into Israel left many Palestinian citizens of Israel (PCI) dead or injured. In the West Bank and Gaza Strip, since 1967, after the Six Day War when Israel occupied the territories, the local population has lived under an armed conflict that has resulted in different types of losses and trauma, including destruction of homes; arrests; invasions; exclusion; deportations; and death of family members (6, 7). Most victims of the armed violence in those two societies were civilian males.

Losses in this paper include both personal (e.g., life, health, severe injury, loss of freedom) and property losses (e.g., destruction of all or part of the home). Loss and trauma are cause and effect components that feed each other: losses cause trauma and, in return, some traumas frame the meaning of the loss, and influence recovery.

In the study reported here, I adopted for the West Bank group the definition of trauma proposed by Afana et al.

(7) for the Gazan society, since the social texture and the ethno-cultural background of Palestinians in the West

Khawla Abu-Baker, PhD, POB 2320, Akko, 24316 Israel.

khawla.abubaker@gmail.com

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Bank is similar to that in Gaza. Afana et al. (7) found that Palestinians in Gaza developed their own definitions for “trauma,” in which the religious beliefs provide explanations for the trauma and suggest coping mechanisms.

Afana et al. (7) suggested that the definition of PTSD as it appears in the DSM-IV does not always fit the state of Palestinian victims in Gaza or in other non-Western societies, especially for those that have undergone prolonged exposure to ongoing sources of traumas. The authors observed that the local population uses their own idioms to grade the types of traumatic events according to their degree of severity, to describe long-term effects, and, ultimately, to make the decision to resort to treatment.

Not all traumatic events cause pathology and not all victims need therapy. Most will recover within weeks after the traumatic event (2). Moreover, Woodcock (3) claims that loss and trauma can even cause positive existential change, mainly for people who are supported by their spirituality. Importantly, spiritual beliefs frame the moral meaning that people ascribe to traumatic events (8).

Approximately 82% of Palestinians in Israel (9) and 93% of all Arabs in the Middle East (10) are Moslems.

Islamic traditions influence all Arab societies, including those of the Christian faiths. Islam defines traumatic events as “tests” for believers, stipulating that they should accept their fate unquestioningly from Allah/ God, to empower their faith (11).

Clinical studies conducted in Gaza clarified the correlation between positive coping with loss and traumatic events and the availability of a positive social support system for traumatized persons and their families.

The notion of being supported helps reinforce the individual’s and the collective’s resilience to the loss (12).

Palestinians in the West Bank and Palestinian citizens of Israel (PCI) have the same ethno-cultural background.

Ethno-cultural mental health research emphasizes the influence of ethnicity and culture on the expression of psychological distress (13, 14). In general, people respond to loss and trauma in congruence with their own cultures (8).

Objective I compared the specific reactions of Palestinians to personal loss following armed conflict events. Two different projects (Projects I and II), one in the occupied West Bank and the other in Israel provided the data for the study.

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Methods Project I

Research conducted in 2002, with a sample of 301 women in the West Bank, showed that almost 99% testified that they had been harmed during the Second Intifada: 49%, experienced damage to their houses; 28% were traumatized by the imprisonment of one or more family members; 13% suffered from the physical disablement of a family member; and 10% lost one or more family members killed by the Israeli Army (IDF) or by Israeli settlers. The majority of the women, 65%, claimed they were unable to return to normal life after the loss, while 75% of them used religious belief as a coping strategy (15).

The author planned and supervised support groups provided for approximately 21% of this group of women to help them to alleviate their loss and grief.

Participants. The target group included 64 women who were part of a larger study group (N=301) (1).

They were recruited through an advertisement offering psycho-social group support for women who had been exposed to loss or trauma during the Second Intifada.

Three psycho-social support groups were organized in three areas: the Bethlehem and Nablus regions and the Jenin refugee camp. Each group was led by two local female social workers during the period of 2002-2003.

The number of participants in each of the three sites varied between 18-24 women.

Participants were all Moslems, aged 19 to 67 years, and with education ranging from 1 to 16 years, as follows: 1-6 years, 35.0%; 7-9 years, 30.0%; 10-12 years, 23.5%; and 13-16, 11.5%. Almost all (n=63) women had been married and had children prior to the loss event.

Four women (6%) were gainfully employed, while all others were housewives.

The types of loss or injury sustained by the participants were as follows: partial or total damage to their home, 48.5%; loss of husband, 20%; loss of child(ren), 26%; internment or imprisonment of family member(s), 20%; chronic physical disability, 13.5%; and stalking, 1%.

Of the participants, 41% suffered from at least two types of losses; 16.8% from at least three types of losses, and 9% from all types of losses. Participants included mothers and widows of shahids/martyrs (as people killed by the IDF are known locally) while one participant (the only single woman), had been injured in an attack on the Jenin refugee camp, she has been left quadriplegic.

She also lost her home, two siblings and an aunt.

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In comparison with the two subgroups from the other two sites, the Jenin group had twice the number of participants who reported that their homes had been demolished following the IDF invasion in 2001.

Procedure. The support groups met once weekly, for three-hour sessions over five months. Sessions included pre-planned updated weekly content, corresponding to participants’ current needs. The sessions were prepared and supervised by the author.

Participants opposed audio-recording of the sessions fearing that tapes might be found by the IDF and reveal sensitive information. Therefore, all conversations were documented verbatim (by two social workers) and analyzed (by the author) using thematic analysis and content analysis, according to the Dye protocol (16). Care is taken here not to provide identifying details of the participants and the transcripts are stored securely to maintain confidentiality.

Analysis

To enhance trustworthiness of the findings the following strategies were used: To enhance objectivity (17), themes suggested by the author were compared with those suggested by the social workers who documented the sessions; To enhance external validity (17), themes raised in each of the three groups in each session were compared; To test consistency (17), themes emerging from the support groups were compared with the results of the background research that had been conducted with 301 women (1); and To reinforce internal validity (17), the narrative and types of reactions of each participant were recorded and followed up in detail throughout the project.

The results of the thematic and content analysis of the support groups’ transcripts are presented after introducing the second project in the next section.

Project 2

According to the author’s perception, PCI have not been allowed to adequately vent their feelings with regard to their exposure to the national and military trauma which preceded the establishment of the State of Israel, feelings that grew with each war in which Israel was involved (18).

Although Palestinians in the Palestinian Authority (West Bank) and PCI have the same ethno-cultural background, since 1948, PCI have not been at the frontiers of any of the Israeli wars. PCI are exempt from

army conscription, and most wars took place at a distance from their homes. The Second Lebanon War (SLW) situated PCI in the frontline facing Hizbollah’s missiles, fired from Lebanon. The war lasted 34 days, exposing PCI to losses and trauma, e.g., destruction of their homes, physical injuries and death. Nineteen of the 44 Israelis killed during the SLW were PCI. Three families of PCI who sustained deaths and one family of a severely injured victim were referred to the author for individual and family therapy.

Participants. The group of PCI included persons considered eligible according to National Insurance Institute criteria to receive individual or family therapy after war-related loss. Four families were referred to the author. In the first family, only the mother agreed to therapy; in the second, five out of seven members; in the third, all six members; and in the fourth family, all eight members. A total of 20 people were in therapy for periods of four months to three years as detailed below: Of the group, a Christian widow, age 66, residing in a large city had lost her son, age 28, in a terrorist attack at his workplace, a year prior to the SLW. Two adult sons refused to participate in the family therapy sessions.

The second family unit included a Moslem family residing in a village, consisting of a widowed mother, age 56, and four daughters. The oldest daughter (age 31) was single, another one (age 30) was married, the third daughter (age 24) was a widow, and the youngest daughter (age 14) was single. The mother and her 30-year old daughter were housewives, her oldest daughter worked in a factory and the two younger daughters were students.

Two additional children refused to participate. This family had lost a daughter (age 25) and her young son (age 5); while a younger grandson (aged 2) remained handicapped. In addition, the family sustained severe damage to the home. All losses were caused by a missile fired from Lebanon during the SLW. The third family unit consisted of a Moslem family that resided in a mixed Moslem/Christian city. It included the two parents (the unemployed father, age 46 and the housewife mother, age 41), three sons (ages: 17, 15 and 11) and three daughters (ages 16, 9 and 6).

All children attended school. The family lost two boys (ages 6 and 9) in a missile attack from Lebanon during the SLW. Prior to their referral to family therapy, a clinical psychologist had made the following diagnoses: the father, dysthymia; the mother, chronic depression; and the three sons, PTSD. The last family unit consisted of a Moslem family from 213

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a large Moslem village and included the two parents and their four children. The father (previously a builder) was severely injured when a missile fired from Lebanon fell on his car during the SLW leaving him with a severe head injury and quadriplegia. At the time of the injury, the father was 39 year old, the mother (a shopkeeper), 34 years old, and the children were 15, 14, 10 and 8 years old, respectively. The father became violent, abusing his wife and children verbally and emotionally. The wife was depressed and felt hopeless. The oldest son showed aggressive behavior towards his mother and teachers.

Procedure. Sessions were scheduled on a weekly basis excluding holidays and memorial days for the victims.

They took place in the clinic with some home visitations. The therapist participated in a memorial ceremony at the cemetery. Detailed protocols were documented by the therapist during and immediately after each session.

The bereaved Christian mother received individual sessions for 18 months. Members of the second family had both individual and family sessions during three years. Therapy with this family was interrupted several times due to additional losses: the death of an uncle and the unexpected killing of a son-in-law in an accident.

Members of the third family received both individual and family sessions, while the parents also underwent marital therapy and parental guidance. This family remained in therapy for about six months. The fourth family received individual and family therapy sessions, sometimes in the family home. Therapy was interrupted due to emergency hospitalizations of the injured father.

The family only participated in ten sessions.

Analysis

To enhance trustworthiness of the findings the following strategies were used: The large number of therapeutic sessions from which the information was gathered guaranteed rich and complete personal narratives. This enabled the identification of subjects repeated by the same clients over a period of time; this increased the reliability of the data (17); The identification of common themes in the four cases in therapy also improved reliability (17); All family members were treated individually, thus the loss narrative was heard from various sources within the same family, allowing comparison of thematic representation. This procedure improved external validity (17); To improve external validity (17), the author studied loss narratives of particular participants in different 214

family therapy sessions, comparing the different narratives, attitudes, feelings and coping systems of those particular persons at different times; and Internal validity was established by comparison between the themes documented by the therapist immediately following each session with themes emerging from content analysis following therapy termination.

Results This section provides a synthesis of the results of the two projects. Eight main themes emerged from narratives in Project I, as follows: “types of losses within the same family”; “repetition of loss”; “immediate reactions to loss”; “long term psycho-social consequences due to loss”; “searching for meaning for the loss experience”; “changes in the family’s socio-political status”; “relations with authorities”; and “internment, imprisonment”; and “stalking of family members.” The themes that emerged from the narratives in Project II resembled those that were identified in Project I except for the last theme (internment, imprisonment and stalking of family members) that was only reported among women in the occupied territories.

Degrees of loss

We grouped the two themes related to loss (i.e., “types of loss within the same family” and “repetition of loss”) under one theme, “the degrees of loss.” Participants who experienced multiple types of losses, or experienced the same type of loss more than once, as well as those who learned from the experience of these participants, reported differential reactions to loss and different levels of bereavement intensity as a result of the type of loss. Of the 64 women who participated in Project I, 52 (approximately 80%) had experienced multiple losses as a result of a single event, such as the killing of a family member and destruction of the house. An example of the multiple losses endured by some of the participants was described by one of the women: following the injury of a “wanted” family member, his arrest after a few months and sentencing to life imprisonment, the father developed depression and the family endured loss of income.

Women who experienced loss described their own degree of loss. The different degrees were discussed and most women agreed that they could grade their degree of loss in relation to the level of intensity of their bereavement. These degrees of loss ranged from low to

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high and included: loss of objects; loss of houses; being chased; arrested; administrative detention; prosecution; long prison sentences for family members; severe injuries causing chronic disability; severe injuries causing constant life threat and later death of a family member; death of a family member; death of an entire family; deaths in the neighborhood. Participants in the three sites agreed that severe injury of a family member that left the injured person under constant threat to life and in need of continuous and intensive care by the family was the most difficult loss to manage. A mother of a youth, age 18, killed by the IDF and a girl, age 12, injured by an IDF shot that caused paralysis in her right limbs and left shrapnel in her right lung said: I buried my son then spent three months with my daughter in the hospital in Jerusalem, then they sent her to Amman for a month and I left everything and stayed by her bed. Then they said that Qatar would help to rehabilitate her in Jerusalem so we returned. But alas, nothing helped her really. I would rather have lost my home and all my money instead of losing my son and watching my daughter being severely handicapped.

The bereaved women emphasized the Islamic prohibition of crying and shouting as expressions of sorrow. They believed that this behavior would harm the dead person when s/he reached heaven. This restriction of active expression of sorrow affected the expression of depression and sometimes caused somatization. Women who experienced the highest degree of loss expressed their sorrow by detaching from ordinary life, avoiding communication with their family, spending most of the days sleeping and nights praying. Finally, they abstained from their enjoyable daily routine behaviors, such as wearing new clothes, and deprived themselves of such small pleasures as eating their favorite food or food favored by the deceased.

Although PCI did not experience some of the losses and traumas described by the women in the West Bank, they did share the sense that there were different degrees of loss and reacted similarly to the degrees of loss identified in the West Bank. Two of the families in therapy had experienced several types of loss (two deaths in each, beside a severely disabled child and home damage). The reaction of these families to loss was reflected in the reported long-term depression of family members and PTSD among some siblings. For example, the wife of the victim who suffered from quadriplegia felt that her family’s loss was the most painful. She said: His situation has worsened since he was injured. Our life deteriorates with his condition. What can I expect

for tomorrow? Nothing really positive will happen in the condition of my husband.

Loss as a collective experience

The themes: “immediate reactions to loss” and “longterm psycho-social consequences due to loss” were grouped together under “loss as a collective experience.”

The bereaved wives and mothers emphasized that they reacted to loss together, as a collective. They were surrounded by significant others from the first moment they experienced the loss. Following severe traumas, for example when a family experienced multiple losses, literally hundreds, and sometimes thousands of people, including strangers, visited the family in an attempt to provide support. A mother in the Bethlehem site said: I heard in the news about the shot in the street. In five minutes people gathered outside my door. I understood that the person shot was my son … From that moment and for the rest of the month relatives, neighbors and people that I never knew did not leave me alone. They took care of the logistics of the funeral and the needs of my family. I felt that they behaved as if my disaster was theirs.

Due to the intensity of loss in the West Bank bereaved women had to spend time visiting mourning families.

The fact that the expression of their psychological grief was restricted by religious proscriptions magnified the significance of these visits turning them into a legitimate social activity for these women, helping them to share the loss of others in order to digest their own loss, allowing them to repetitively retell their own loss narrative. Thus, this activity functioned as group therapy.

The group of PCI who experienced loss during the SLW was very small. They were unable to share their specific war-related loss with people who experienced other losses. The Christian mother felt supported by the intensive visitation of her relatives and community. But, surprisingly, she felt unable to visit any mourning family. She said: “I was unable to see mothers, who reminded me of my situation, when my loss experience was very fresh and deadly painful.”

Traumatic event as a message from Allah/God

Participants in both projects searched for meaning for their loss experience, asking questions such as “Why God, why me, why my husband, daughter, children, home?”, sometimes in agony, weakness, anger, distress and as a cry for help. Searching for meaning, participants in both projects related to the loss as a message 215

Reactions of Palestinian Families Following War-related Losses

from Allah/God. The title of the theme was revised to reflect this conceptualization.

Participants who experienced traumatizing events mentioned the name of Allah intensively, reminding themselves and others of Allah’s intentions toward them.

Immediately following the traumatic event, they started a new dialogue with Allah and moved through five stages vis-à-vis their relation with Him: (a) initially they questioned Allah’s reasons for choosing them to suffer this event, (b) they blamed Allah for His harsh treatment or blamed themselves for insufficient obedience, (c) they understood their helplessness and need of support, including supernatural sources of support, (d) their religion was reborn or they emphasized their religiosity, (e) they revised their previous decision when they returned, several weeks or months later, to their regular life. The stages of this dialogue seem to resemble the stages of reaction to trauma that begin with questioning the traumatic news and end with accepting the traumatic event (19).

People who are not acquainted with Arab or Islamic culture find it hard to understand that a traumatized person or bereaved parent can praise Allah for their loss. We understand this phenomenon as the traumatized persons’ conclusion that they will never actually be able to control all aspects of their life since there are forces more powerful than them. A woman from Nablus region, who lost two children in the Second Intifada, and whose third son’s lungs were severely injured, said: Praise Allah. When my first son became a shahid/ martyr, I behaved like a crazy person. I shouted to Allah, I blamed Allah, I stopped praying, I was very angry. My family was very angry… When my second son was killed 45 days after his brother’s death, I was paralyzed emotionally. I did not know how to react. I just kept asking Allah, why? Tell me why? … Three months after the death of my second son, my third son was injured. When people ran to tell me about my third son’s injury, suddenly I understood that Allah is sending me messages that I have to understand. My reaction to people who came to share my sorrow was just one sentence “I praise what comes from Allah,” “Thank Allah.”

Another PCI mother who lost her young daughter cried out at first against Allah’s “choice” of this daughter who had performed all her religious duties. Later the mother convinced herself that the loss was a message from Allah, believing that Allah chose the best of her family members for His heavens. The mother felt that she had understood the message: “my daughter was a gift from Allah to us. He wanted his gift back.”

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Changes in the family’s socio-political status

The social status of mourning West Bank families changes immediately after the loss and they are thenceforward seen as “relatives of the shahid.” They gain social respect at the community and national levels.

Some represent the “shahid families” nationally and internationally, including on national TV. Some PCI called their deceased beloved ones “shahid.” A sister of a young woman killed in a missile attack said “The only thing that consoles me is my knowledge that my sister is in heaven with shahids and prophets.”

Another sister of the same deceased said “Now she will help us to be forgiven for our faults on the day of resurrection.” A father said “I received condolences from Sheikh Nasrallah addressing our children as shahids. My children did not die for nothing.”

The discourse on the “shahids” left the Christian mother with a disharmonious feeling concerning the Islamic nuances of the title. She blamed the Palestinian suicide bombers for the escalated violence that killed her son. She related to a woman suicide bomber as her enemy and was full of resentment towards her.

Comparison between the two groups showed that while in the West Bank mourning families gained socio-political respect, in Israel, they were awarded the sympathy of their communities.

Relations with authorities

In the West Bank, families of “shahids” receive a small monthly pension from the Palestinian Authority.

For many families, this pension is the only source of income. Whenever both the widow and the mother of the “shahid” claim to be the sole beneficiary, disputes may disrupt family relations. If the mother receives a pension for the loss of her son, this may allow her to control the daughter-in-law. Some widows became politically active to influence Palestinian Authority’s policy concerning pensions.

Women in the support groups related to the State of Israel as “the enemy.” This declaration was met with socio-political support. Externalizing the identity of the enemy also allowed them to overlook enmity among Palestinian groups.

One member of the PCI group also related to Israel as “the enemy.” He accused the State of causing his children’s death since Israel had not made peace with the Arab world. Most participants sympathized with Hizbullah, especially after Nasrallah (leader of Hizbullah) sent his personal condolences to each mourning family. These

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communications from Nasrallah were kept private since the families feared that the State might punish them by confiscating pensions and other benefits that families of war victims received.

Internment, imprisonment and stalking of family members

This theme frequently emerged among the members of the West Bank support groups but it did emerge occasionally as a significant theme among PCI as well. Some of the women in the West Bank reported a lifestyle that included fighting against the IDF, (e.g., to escape, to be chased, arrested, sentenced and imprisoned). One woman said that in her 22 years of marriage, her husband, an active member of the resistance, never slept at home for five consecutive nights. Stories shared related to fear of being caught, ways of infiltrating in and out, IDF night attacks on homes, queuing for permission for jail visits, long day trips to the jail for 30 minute visits, etc. Although these women raised their children almost alone, they never related to themselves as single mothers. This description signified the death of the father that they tried to prevent with all their power.

Gendered reactions to loss or injury of a spouse

Members of the support groups described a widow who decided to marry a stranger and move away after the death of her husband, as a cheating wife. Traditionally, young widows are expected to marry the deceased’s brother or to deny their need for a partner, investing all their emotional resources in their maternal role. Yet, when the deceased person was a woman, it was acceptable for the husband to remarry a few months after the death. A mourning mother from the Nablus site said: My son was married for three months when he was killed. Three days after his burial, the family of his wife moved her back to their home. It was like another stab in his dead body. His home was closed forever.

This understanding that a man should live a complete life also appeared in therapy with PCI clients. A mother whose daughter had been killed said: I was very sad when her husband remarried. But I understand him. He is young. He has a handicapped son that someone has to take care of. He should remarry.

Discussion The analysis of the two projects assumes that Palestinians in the West Bank and in Israel share the

same ethno-cultural background. This partly explains similarities in the two populations’ reactions to warrelated loss. Mental health service utilization by the two populations is very limited and mostly negatively stereotyped. However, local traditions in both the studied regions have developed procedures that serve as ethnocultural services to maintain mental health.

One of the major features of individual reaction to loss that emerged from the findings is that the individual loss is experienced together with the collective. Because loss became a daily event in the West Bank (especially during the Second Intifada), and because some families experienced various or repeated losses, they became “experts” in understanding the feelings of bereaved persons. Extreme interpretation of Islam forbids mourning people to shout, cry loudly or inflict self-injury to express deep sorrow during bereavement. Mourners repeatedly visited other mourning families in an attempt to continue to vent their loss and search for a new meaning to their loss. This practice resembles supportive group therapy and narrative therapy for both the fresh mourners and those with a longer experience of grief.

In such gatherings, bereaved veterans shared details of the types of loss they had experienced and assessed theirown degree of loss, in comparison with recent losses in their community and larger society. This, in turn, helped the audience to assess their own loss comparatively in the same way. When people experience helplessness following what they deem as a disastrous loss, assessing their own loss in comparison to losses of others brings some comfort and consolation. These intensive meetings exposed the bereaved to available choices of after-loss life style and activities, adopted by other people.

Like the bereaved of the West Bank, individual grieving PCI also experienced all types of loss within the collective. However, they lacked the community’s longitudinal management of war-related loss because the SLW was the first event in which the Palestinian population experienced such a loss. The group of families that were referred to therapy had no opportunity to meet with one another. However, details of their loss were published in the Arab newspapers and on-line.

This allowed people to assess the degrees of loss and to compare family members’ narratives in therapy.

The study reveals that the nature of the relationship of each population with the State of Israel influenced some reactions to war-related loss. Palestinians in the West Bank were unequivocally proud to be known as the “family of the shahid(s),” a title accompanied by social 217

Reactions of Palestinian Families Following War-related Losses

prestige and sometimes financial compensation or pension. In comparison, socio-political reasons cause PCI to hesitate to adopt such a title publicly. This study revealed that a bereaved Christian mother did not empathize with the title because she did not share the same Moslem religious value of the “shahid.” This concept also raised questions regarding the identity of the “enemy” when the death of PCI was caused by other Arabs or Palestinians.

The situation was more complex for this group due to the financial and psychological support that this group was eligible to receive from the State of Israel, inasmuch as the character of the State became ambiguous as the enemy and supporter, comforter and rescuer.

Finally, although the three support groups in the West Bank incorporated only women, including the social workers who facilitated the meetings, a substantial amount of information was documented in the women’s narratives regarding reactions to loss of husbands, sons, brothers, in-laws and other male family and community members. Thus too, the PCI group, dealing with the loss caused by war, generated significant information regarding its political attitudes toward the State of Israel, the Israeli-Palestinian ordeal, the relationship between Israel and the Arab world, the attitudes of PCI toward Islam and Islamization of the conflicts in the Middle East.

Although the two projects aimed to investigate the reactions to war-related loss, the narratives that were collected reflected rich knowledge highlighting parentschild relationships at all ages and the status of women within their families and societies. It is however noted that due to the qualitative nature of the data, any generalization to other similar circumstances is limited.

Acknowledgement

The West Bank project was funded by Kvina Till Kvina (Women to Women) and Sida, Sweden, hosted and directed by the Women’s Studies Center, East Jerusalem.

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Available from: URL: http://www.cbs.gov.il/reader/shnatonenew.htm 10. Fargues P. The Arab Christian of the Middle East: A demographic perspective. In: Pacini A, editor. Christian communities in the Arab Middle East: The challenge of the future. Oxford: Clarendon, 1998: pp.

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Isr J Psychiatry Relat Sci - Vol. 49 - No 3 (2012)

Three Years of Isha Be-Shela, A Women’s Counseling Center in the Negev – a Mixed Method Analysis Julie Cwikel, PhD, Director, and Andrea Ifergane, Clinical Director The Center for Women’s Health Studies and Promotion, Ben-Gurion University of the Negev, Beer Sheva, Israel

ABSTRACT Background: A university-based counseling center for women, Isha Be-Shela, was established at BenGurion University of the Negev in 2008 based on multicultural, feminist treatment models. Psychotherapy is provided by mental health professionals in a variety of treatment methods. Method: 122 cases from the first three years of operation were analyzed for demographic features, presenting problems, referral, type and length of treatment. Two cases illustrate principles of gender and cultural sensitive therapy.

Results: This analysis provides a cross-section of the mental health issues that Israeli women face and that propel them to seek mental health treatment. Trauma was reported by 62% and a past or present health problem by 38%. Limitations: The use of validated mental health assessment measures might provide a fuller picture of the range of presenting problems and treatment outcomes. Conclusions: The presence of an early trauma often accentuates women’s mental health distress and physical health and becomes an underlying issue in psychotherapy.

Acknowledgements:

The authors would like to express their appreciation of the support of the estate of Ms. Goldie Ivener, a mental health professional from Los Angeles, which was instrumental in establishing Isha Be-Shela. In addition, we thank Ester Lilian and Nirit Segal for their help with the data entry and analysis. Finally, we value the excellent work of all the psychotherapists of Isha Be-Shela, which made this paper possible.

Address for Correspondence:

POB 653, Beer Sheva 84105, Israel.

Background A consistent feature of psychiatric epidemiology and of mental health care utilization is that women report more depression and anxiety disorders than men and seek care for mental health problems more often than men both in Israel (1-3) and abroad (4-9). The burden of biological, reproductive roles and concomittant hormonal changes and the exposure of women to adverse experiences such as poverty, child sexual abuse and blocked opportunities in education and the workforce are postulated as explanations for the higher prevalence of depression and anxiety disorders among women (3, 8). In addition, it is more socially legitimate for women to express distress and seek help for mental health problems, while men sometimes mask their depression and anxiety through substance abuse and anti-social behavior (1, 10, 11). In Israel these differences are particularly salient among marginalized groups, e.g., immigrants from the former Soviet Union and from Ethiopia and Arab groups (1, 12-15). A recent study of mental health service use among women showed that psychosocial risk factors such as unmarried family status, lack of suitable employment, low levels of educational attainment, chronic illness and exposure to domestic or sexual violence explained only part of the excess in service utilization. Even after controlling for these co-variates, female gender still remained a significant predictor of service use (1). Thus, there are unique aspects of women’s societal, working, familial and reproductive roles that increase their mental health risk and that require the development of both gender and ethnic sensitive modes of treatment (4, 8, 16-22).

The Negev, the southern region of Israel, is the most sparsely populated region in the country. It includes a high percentage of immigrants, Jews from the former Soviet Union, Ethiopia, East and West Europe, North jcwikel@bgu.ac.il

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Three Years of Isha Be-Shela, A Women’s Counseling Center in the Negev – a Mixed Method Analysis

Africa, and North and South America, as well as a large Arabic-speaking Bedouin (formally nomadic) community. Economically, it is an underprivileged region, with a high rate of unemployment. This constellation of socio-demographic profiles makes this region rather unique (23). Thus, many psychosocial risk factors, such as poverty, low educational attainment and a high proportion of immigrants are particularly acute in the Negev. A recent study demonstrated that approximately one-half of those who suffer from psychiatric disorders do not receive mental health services in Israel (24), but this situation is exacerbated in the peripheral areas such as the Negev where this rate is but one-quarter of those with emotional distress (25).

Gender and Culturally Sensitive Therapy

An eclectic, yet unique approach to treatment developed out of the social consciousness and critique of traditional gender norms for women that began with the women’s U.S.-based movement the 1960s (26-28).

Early psychologists focused attention on the way that traditional Freudian psychotherapy was a prism for understanding how society viewed and socially controlled women (29, 30). With accumulating evidence, it became accepted that cultural gender norms, social locations and the distribution of power in society significantly shape women’s mental health and their health in general (1, 6, 8, 15, 28, 31-34). Women often seek treatment due to sexual trauma but then are met by “more of the same” in the relationship with their male psychotherapist who exploits the therapeutic relationship unethically (26-28). This gave further impetus for developing more open, democratic, trauma-informed, gender and cultural sensitive practice (26, 32, 35).

This theory and research knowledge was the basis for the development of a local, Negev-based gender and culturally-sensitive practice for women. Our approach emphasizes the expertise and “voice” of each woman as she reflects on her unique needs and experiences, evoking her strengths as resources in treatment rather than focusing on psychopathology (27, 36). Laura Brown posits, “Feminist practice aspires to the creation of an egalitarian relationship between therapists and clients.

Clients are construed as possessing expertise and authority about themselves, their lives and their needs. Therapy then becomes a process of empowering clients to identify and own that authority” (27, p. 465). Judith Worell articulated this stance relying on therapeutic goals that constitute the framework for psychotherapeutic work in 220

Table 1. Therapeutic goals in Gender and Cultural Sensitive Therapy (Worell, 2008 [36]) General goals in therapy: 1. Promote positive self-esteem and intrinsic value 2. Increased comfort in daily functioning and reduction of distress 3. Problem-solving: Use of relevant problem-solving skills 4. Personal control: perceived internal control/self-efficacy 5. Resource Access: Access/use of personal community resources Gender and culturally specific goals in therapy: 6. Gender/culture awareness: behavior informed by gender/culture power analysis 7. Self-nurturance: ability to meet needs, avoid abuse 8. Flexibility: Selectivity in use of behavior informed by one’s gender/ culture 9. Assertiveness: Respectful confrontation/refusal skills 10. Social Activism: Activity toward change for social justice

our service (see Table 1) where five goals are common to all psychotherapy while others emphasize gender and culturally-sensitive practice (36).

Isha Be-Shela - Description of the Service

Through the aegis of the University’s Center for Women’s Health Studies and Promotion, Isha Be-Shela (“a woman in a place of her own,” freely translated) was established in August, 2008. The service was modelled after the Counselling Center for Women (CCW) which has operated services in Ramat Gan and Jerusalem as a freestanding non-governmental organization (37). Isha Be-Shela is unique in Israel, as the academic setting allows for students to participate in training, research ideas and projects to percolate and access to the cutting edge of feminist theory and practice. We place an emphasis on: understanding gender as an organizer of social and cultural position, establishing collaborative therapeutic relationships with an appreciation that the client is considered the expert on her own life, integrating between mind and body in understanding the development of symptoms and promoting empowerment, self-care and self-nurturance in recovery. In general the therapeutic approach depends more on understanding the reasons for distress instead of concentrating on pathology and psychiatric labels. Thus, for example we understand the insidious nature of trauma experienced by women and disadvantaged groups as contributing to the unique patterns of women’s distress (26, 28, 32, 37-39).

Since its inception, more than 130 women (over the age of 18) have received ambulatory mental health services, using a variety of treatment methods (dynamic ego psychology, short-term, long-term, narrative therapy,

Julie Cwikel and Andrea Ifergane

psychodrama, art therapy, cognitive behavioral therapy).

We have also conducted seven group interventions in areas such as women’s sexuality, parental coping, empowerment of women in development towns, and promotion of mental health among middle-aged women.

Isha Be-Shela employs 15 part-time psychotherapists (including one male psychotherapist), all with MA or higher educational attainment in social work or psychology, experienced in psychotherapy with women.

Intakes are for the most part conducted by the second author and supervision is provided to the staff by both authors. A unique in-take procedure was developed to reflect both cultural sensitivity and an awareness of the impact of both biological (experience of pregnancy, abortion and childbirth) and trauma experiences (child sexual abuse, domestic violence and other types of violence and/or trauma). This is detailed below.

Process of Referral and Intake to Isha Be-Shela

Following referral, the administrative coordinator contacts the woman and explains the intake process and the cost of treatment. The prospective client is sent a self-administered background questionnaire based on questionnaires used in CCW and other mental health clinics to complete prior to the intake interview, which averages 90 minutes. The questions include: the presenting problem, reasons for coming to treatment, family and network history and relationships, health events, eating disorders, trauma history, sources of support and positive personal coping strategies and substance use.

During the intake, these issues are expanded and we specifically address reproductive history including pregnancy, abortion, birth and, if suitable, menopausal symptoms are explored. Specific questions are asked about army service, educational frameworks and employment. Following intake, the best match between client and psychotherapist is made with the following factors taken into consideration: main issues identified in the intake, preferred and appropriate method of treatment, cultural and religious background, preferred language for treatment (Hebrew, Russian, English, Spanish and Arabic) and sexual orientation. Hours available to the patient are matched to suitable psychotherapists. Isha Be-Shela has been officially recognized as “gay friendly” by the Israeli Network of Gay and Lesbian Psychotherapists. Despite attempts to maximize the suitability between clients and therapists, if clients feel there is a lack of compatibility, they may request another therapist. This has happened five times in the

past three years, suggesting a high rate of matches that seem to meet the clients’ needs.

This paper presents qualitative and quantitative data on the development of a university-based counselling program for women in the Negev that developed out of a deep understanding that Israeli women’s unique life experiences require the development of gender and cultural specific therapeutic skills. We report here on the first 122 cases of individual psychotherapy from the first three years of operation.

Method Since the service opened until July, 2011 information was collected on all the clients (N=143) who completed an intake interview. Of them 18 (12%) did not continue, while three files had incomplete information. Data on the remaining 122 cases were entered from the in-take self-report questionnaires, the intake summary and the treatment files into SPSS (version 18) for analysis.

Descriptive analyses were conducted using frequencies, t-tests and chi-square analyses. All diagnostic and stressful life events are self-report variables (e.g., type of trauma, presenting problem) which then were developed into coding categories based the clinical judgment of the two authors based on prior research (40, 41) and a review of all the responses. The evaluations were made independently by the two authors and when there were cases of discordance, they were discussed until a single concordant code was generated. Two cases typifying the type of unique issues brought to gender and culturally sensitive treatment are presented and discussed.

Results The population: It is largely young with an average age of clients of 32.8 (SD 11.9). The distribution of demographic features is shown in Table 2. The majority were native Israelis (77%), more than half were single (58%), the majority (68%) were working at either full or parttime jobs. In spite of this, most still reported financial difficulties, and only 13% paid unsubsidized fees. The wide variety of ethnic and cultural groups and the economic difficulties is a reflection of the populations of the Negev, although some populations are still unrepresented, such as Bedouin residing in the Negev. This is despite the presence of an Arab-speaking therapist on staff.

The majority self-identified as heterosexual (93%) 221

Three Years of Isha Be-Shela, A Womenâ&#x20AC;&#x2122;s Counseling Center in the Negev â&#x20AC;&#x201C; a Mixed Method Analysis

Table 2. Description of the population Percent % Age

Birthplace

Marital Status

Parity Work Financial Status

20-29

60%

30-39

18%

40-49

8%

50-59

7%

60-69

7%

Israel

77%

Former Soviet Union

8%

North America

4%

North Africa

3%

Ethiopia

3%

Europe

2%

South America

2%

Asia

1%

Single

58%

Married

28%

Divorced

8%

Widowed

3%

Separated

3%

Have Children

39%

No Children

61%

Working full/part time jobs

68%

Not working

32%

Financial difficulties

87%

No financial difficulties

13%

Army or National Service

Served

84%

Not served

16%

Education

High School

18%

BA-student

35%

Completed B.A

24%

MA-student

11%

Completed M.A

7%

PhD-student

2%

Completed PhD

3%

Jewish

94%

Christian

3%

Muslim

3%

Secular

59%

Traditional or religious

18%

No religiosity mentioned

23%

Religion

Religiosity

with 7% having other sexual orientations (gay, lesbian or transgender). All except four clients were female.

Examination of the demographic features of those who dropped out of treatment after the intake shows that there were no differences on age, marital status, educa222

tional level or ethnic origin (all chi square values NS, p<.27). The reasons for not starting treatment included: relocation to another place, economic difficulties, starting treatment in another service and feeling ambivalent about starting treatment.

Treatment Issues: Approximately half (47%) heard about Isha Be-Shela by word of mouth, one-third (34%) were referred by a mental health professional and 19% had heard about it at lectures by the two authors or from seeing a brochure on the service. A little over half (56%) had previously been in psychotherapy, although only 28% had ever been treated in a psychiatric framework. Twenty-two percent reported that a family member had been in psychiatric care. Of the 23% percent of clients that reported receiving psychoactive drugs, 13% were currently still on anti-depressants or anxiolytics. Twenty-nine percent reported ever having suicidal thoughts, of them 10% still reported them, 7% reported a past suicidal attempt. Of the clients, 31% reported some type of substance use or addiction (14% food addiction, 6% recreational drugs, 5% cigarettes, 3% alcohol and 3% some other type).

The self-reported reasons for seeking treatment are shown in Table 3; 29.5% reported more than one reason. The main reasons were, in general, affective distress (45%) including depression, anxiety, trauma, low selfesteem, grief, reproductive events such as pregnancy loss or post-partum depression.

A significant portion of clients reported childhood or recent stressful life events and 11.5% reported more than one event. No traumatic events that would qualify for DSM-IV criteria for PTSD were reported by 37.7% (46/122); however 66.2% had some traumatic event in the past, largely exposure to sexual or physical assault.

Of the 122 clients reviewed, only two brought up traumas in treatment that were not referred to in the intake process.

Approximately half of the traumatic events happened during childhood, including sexual assault, incest, bullying, parental separation and loss and personal injury or illness. Clients also reported being distressed over events that happened to significant others in their network, such as illness, death or suicide (19%). A small portion reported significant traumatic health events (6%). However, in a separate question clients were asked directly about health problems; 38% had a health problem at present and 7% had a significant health problem in the past, the most commonly reported problems being endocrine (14.%), 11% neurological and 11%

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Table 3. Presenting problem (n=158, more than one answer possible) Type of presenting problem

Frequency

Percent of Problems

Affective distress

71*

45.0*

Depression

18

11.4

Anxiety

18

11.4

Grief

13

8.2

Low self-esteem

13

8.2

Traumatic events

5

3.2

Post-partum depression

3

1.9

Pregnancy loss

1

0.6

Interpersonal disputes-conflicts

51*

32.4*

Interpersonal difficulties

6

3.8

Difficulties in family relations

9

5.7

Relationship issues partner

16

10.1

Difficulties finding a partner

10

6.4

Separation – divorce

10

6.4

Role transitions and daily function

23*

14.6*

Adaptive problems – feeling stuck

10

6.4

Perfectionism – control issues

4

2.5

Occupational difficulties

9

5.7

Disordered eating

4

2.5

Somatization

3

1.9

Chronic illness

2

1.2

Sexual identity

2

1.2

Stress

2

1.2

Total

158

100.0

* Count and percentage for category group

reported a previous malignancy. Those who reported a past or present health problem were much more likely to also report a past traumatic event compared to those without health problems (72.7% vs. 53.7%, chi square=4.64, p<.05).

The treatment recommendations were eclectic; primarily (56%) some combination of dynamic long-term therapy with CBT (32% for both, 16% for dynamic, psychotherapy and 8% for CBT alone). Other treatment recommendations were short-term dynamic (12%), crisis intervention and supportive therapy (11%), family oriented therapy (5%), grief work (5%), art therapy (7%) and psychodrama (4%). As of this point in time, 50.8% were still in treatment with visits numbering from 1-115 (mean =25.1, SD=28.3).

The average number of treatment visits for clients who completed treatment (20% or 25/122) is 17.2 (SD=13.5) and for those who left for other reasons (n=35), the average is 7.2 visits (SD = 7.0). Of those who left treatment, the reasons were: 42% finished their treatment, 16.6% had a financial reason, 13% felt stuck or dissatisfied with their treatment, 10% had trouble finding time, 8.5% moved away, 5% left for another treatment framework (public sector) and 5% the reason was unknown.

Interestingly, the average number of treatments for those who did not report a traumatic event prior to beginning treatment was almost twice the number of those who did identify earlier traumatic events before commencing treatment (23.5 (SD=16.1) vs. 12.3 (SD= 8.9), t=2.23, df(23), p <.05). Those with past health problems had a higher average number of visits, 34.2 (SD= 38.5) compared to those with present health problems 15.3 (SD=.22.5) and no health problems 18.2 (SD=19.2) (t=2.03,df(53), t=2.03,df(73) respectively, p<.05, for both post-hoc comparisons). Among those who completed their treatment (n=25), short-term therapy, CBT, crisis intervention and family therapy averaged 7.4, 8.2, 13.0 and 15.0 sessions, respectively; dynamic and integrated CBT and dynamic averaged, 22.3 and 24.7 respectively.

Grief work was the longest average treatment (33.5 meetings). Those clients in art therapy or psychodrama either were still in treatment (27.8 or 29.5, respectively) or left for other reasons (and thus could not be calculated in the “completed treatment” group).

Case Presentations Two cases were selected to illustrate the principles of gender and culturally sensitive therapy in conjunction with common issues that propel women into psychotherapeutic treatment. Identifying information has been modified to protect the identity of the clients.

Case 1 - Regina

Regina, aged 35, married with two children, was born in the USSR and immigrated to Israel in 1991 with her husband and eldest son, now aged 15. Regina is married to an engineer working in high-tech. Their daughter was born a year ago. She has a BA in economics and business administration and works full-time in a bank where she manages a financial group. The oldest of three, Regina grew up with strict parents who had high expectations of their children. She was an excellent student and excelled also in gymnastics. For two years 223

Three Years of Isha Be-Shela, A Women’s Counseling Center in the Negev – a Mixed Method Analysis

she was raised by her grandmother and would see her family only on weekends in order to allow her mother to return to work.

Reason for the referral: Regina was referred from another mental health professional. Just prior to the referral, she had a series of conflicts with a fellow worker who substituted for her while she was on maternity leave and who later tried to undermine her status at work by criticizing her as being too “soft” a manager.

Presenting problems: Reported symptoms included recent sleep disturbances, lack of appetite with weight loss, lack of desire to do things, crying, reduced libido, a feeling of tightness in the chest, heart palpitations, diffuse physical pain, muscle aches, headache, and nervousness. She reported also different types of fears: that her husband would leave her, something terrible will happen to her children, she will be fired from work, and will lose respect from her co-workers.

Process of therapy: Short-term therapy (12 meetings), using CBT (e.g., relaxation techniques, disputing irrational thoughts, behavioral assignments from week to week), focused on anxiety symptoms reduction and psycho-education about her symptoms.

Unique aspects of the feminist therapy included: focus on her work-related function rather than her choices of what to do as a mother and a non-judgmental approach to her priorities as a career woman and mother. The therapist carefully maintained a nonjudgmental stance regarding the differences between her own approach to balancing work and family and her client’s. There were repeated discussions about the meaning of a “good manager” – does she need to bully her employees in order to be recognized as such or can she have an alternative style of management? Does the role of manager require “masculine stereotypical behaviors”? The therapy ended when Regina reported her symptoms had subsided almost entirely and she had regained her former sense of control. This case especially emphasizes the goals #6, 7, 8 and 9 shown in Table 1 (gender/cultural awareness, self-nurturance, flexibility, assertiveness) along with general symptom reduction, problem solving, and promotion of personal control (2, 3 & 4).

Case 2 - Hannah

Hannah, 26, married for three years without children, a resident of a religious communal settlement (moshav), and working as a kindergarten teacher in her community.

Reason for referral: Hannah came for treatment 224

some nine months after a miscarriage at 32 weeks of pregnancy which necessitated a “still-birth” that was similar to giving birth to a live infant. Medical workup revealed a problem with clotting factors of which she had previously been unaware. She was referred by a nurse in her clinic.

Presenting problems: Hannah felt overwhelmed by her sorrow, cried a lot and found it hard to concentrate. She reported difficulty sleeping, lack of appetite, frequent crying spells, lack of energy to work with children, and fear of another pregnancy despite her desire for her own child. She fantasized about how the baby would have been and felt anguish seeing other pregnant women or babies. She felt that in the moshav, where her family also lives, there was no room for her grief. She frequently heard the phrases “G-d gives, G-d takes away,” “G-d works in mysterious ways” and that since something was wrong with the pregnancy she should be thankful. Her mother felt that she should immediately get pregnant again. She felt that nobody understood her feelings and was afraid to express her anger toward G-d. She was taken to a well-known rabbi who gave her his blessings and some talismans, but she did not feel encouraged by this.

Process of treatment: At the end of the intake, the patient asked to be treated by a psychotherapist from a religious background in order to allow dialogue based on greater sensitivity to her issues and social messages.

The treatment focused on expression of grief and loss, giving legitimacy to anger over the situation and with G-d. Unique aspects of the feminist therapy: the treatment focused on incorporating diverse aspects affecting mental health including physical, social and spiritual and gender and discussions of the social norms specific to her macro environment that made her situation even more difficult. The process of the therapy enabled Hannah to differentiate between the social expectations and her own internal feelings and experiences, which sometimes clashed. After discussions with her psychotherapist, Hannah consulted with her local rabbi and conducted a ceremonial memorial for her child at the one year anniversary of her infant’s “un-birth.” One month later, she reported she was pregnant again and preferred to continue psychotherapy to manage her anxieties until the next birth.

During the year after giving birth to a son, therapy continued on a monthly basis to support coping with new motherhood. This case illustrates the judicious use of the first 8 goals in therapy (see Table 1).

Julie Cwikel and Andrea Ifergane

Discussion Given the research indicating that the majority of users of mental health services are women and that there is a significantly lower rate of service use in the periphery (1, 24, 25), together with the documented reluctance of the population to attend psychiatric clinics (42), the establishment of women-focused mental health services in the periphery is particularly important. This paper reviewed the unique treatment approaches and the variety of treatment options offered by Isha Be-Shela, the heterogeneous nature of the populations served, and illustrated some of the ways these methods are expressed in two representative case examples.

Childhood trauma, particularly sexual trauma, is often the precursor of somatic symptoms that develop over the life course (43-46). Recognizing the long-term effects of trauma have made this an important focus in psychotherapy. In our women-centered approach to treatment, women are asked direct questions about trauma both as part of the self-administered questionnaires and during the intake. This shows clients that the subject can be addressed openly and it is valid and important to address these issues in treatment. The negligible number of clients who reported traumas during treatment that were not reported in the intake provides further validation of our methods. The ability to recall traumatic events was found to be related to past and present health problems which were common among women coming for psychotherapy (46, 47).

We found that women with chronic health conditions were not asked about their trauma histories in earlier medical encounters although there is ample evidence that chronic illness is a frequent outcome of repeated trauma and chronic stress (44, 46, 47). The medical system tends to see women who somatize their distress as mentally disturbed and in need of psychiatric treatment, especially medication. We feel that focused psychotherapy can also be beneficial, as our results demonstrate.

The unique aspects of the service described here differs from the Counseling Center for Women in that it generates academic research and publications (2, 3, 47-53), it serves as the training site for mental health professionals and it provides a significant contribution to the mental health services in the underserved Negev periphery. Until now, we have not had the staff and economic resources to engage in community social activism and outreach, although this is one of our long-term

goals in keeping with the principle “the personal is the political” (54). While those who sought treatment represent a wide diversity of clients, there are still sectors such as the very religious or Arab-speaking women that use ambulatory services rarely and for whom focused outreach is recommended.

We have been exploring the use of standardized (2) and newly validated assessment procedures for the service (54), based on earlier work on assessing the efficacy of mental health treatment of women (38). This could add empirical data to evaluate the success of treatment but needs to be introduced before and after treatment to be effective. We are currently evaluating the impact this may have on the treatment process.

This evaluation of three years of work in a new mental health service serving women in the periphery shows that there is a demand for services that are offered at reasonable fees. The current policies of the HMOs to subsidize a small number of treatments would not be sufficient to meet the needs of most who seek treatment.

There is a need to apply the principles of culture and gender-sensitive treatment and make psychotherapy accessible to a wider audience of those in distress.

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Isr J Psychiatry Relat Sci - Vol. 49 - No 3 (2012)

In Praise of Cultural-Competence Training for Mental Health Professionals Julia Mirsky, PhD Department of Social Work, Ben-Gurion University of the Negev, Beer Sheva, Israel

ABSTRACT Background: Mental health practitioners in Israel encounter clients from a variety of ethnic groups and cultural backgrounds. Yet, culturally-informed practice standards have neither been defined nor promoted by the professional establishment. Method: A model for cultural-competence training for mental health professionals is presented and evaluated based on self-reports of 51 trainees. Results: An increase in the trainees’ understanding of their clients’ cultural experiences is elicited, as well as the expansion of their cultural self-awareness, empathy and respect for cultural diversity. Limitations: This is a qualitative evaluation with a limited number of respondents and provides data only on short term effects of the training. Conclusions: The evaluation demonstrates positive training effects on the practice. Hopefully, this experience will encourage addressing cultural issues in the practice and training of mental health professionals in Israel.

In recent decades, with migration becoming a worldwide phenomenon, mental health practitioners in many Western countries encounter a growing cultural and ethnic diversity among their clients. Accordingly, mental health practitioners have recognized that cultural competence is essential to their practice.

Canada is an example of the most progressive country regarding attitudes towards cultural competence, as reflected in the 1971 Canadian Multiculturalism Act. A variety of cultural training programs in mental health are offered by public and academic organizations Address for Correspondence:

throughout this country (1). Many such programs also exist in Australia, e.g., the Multicultural Mental Health Australia (MMHA) is a national program to improve awareness of mental health and suicide prevention in its culturally and linguistically diverse communities. Also, major mental health professional organizations in the United States took action to promote such a competence among their members. The recognition of the American psychiatric establishment regarding the importance of providing culturally-responsive clinical conceptualization, assessment and treatment is represented in the inclusion of the Cultural Formulation (CF) of Diagnosis in Appendix IX of the DSM-IV (2). The components of cultural formulation are, among others: the patient’s cultural identity, cultural significance of symptoms and behaviors, cultural explanations of illness and overall cultural assessment for diagnosis and treatment. Developed by an international team, the CF is being researched and disseminated around the world (3-6). Similarly, the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists, formulated by the American Psychological Association, provide a context for culturally-sensitive service delivery (7). Psychologists are encouraged to apply culturally appropriate skills in their practice, as well as to develop practices attuned to the unique worldviews and cultural backgrounds of their clients.

The American National Association of Social Workers (NASW) has published Standards of Cultural Competence that recommend social workers to strive to deliver culturally-competent services (8, 9). Under the current Education Policy and Accreditation Standards of the Council on Social Work Education, students are to be taught how to define, design, and implement strategies for effective practice with persons from diverse backgrounds (10).

Ben-Gurion University of the Negev, POB 653, Beer Sheva, Israel 84105

juliamirsky@gmail.com

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A wide diversity typifies European countries in their recognition of the importance of cultural competence in mental health. However, European or national comprehensive policies are lacking in this respect. While northern-European and traditionally migrant-receiving countries such as the United Kingdom have a more developed approach to cultural competence training, southern-Mediterranean countries have just recently recognized the need for such training. Lack of attention to cultural issues in practice and policy is noticeable in eastern European countries (11).

The persistent endorsement of cultural competence in the mental health professions, mostly in North America, led to the development of a variety of models for culturalcompetence training. These models share the understanding that three basic elements are the perquisite for effective cross-cultural practice: cultural awareness, cultural-specific knowledge and skills (5, 12-14). However, they differ in their conceptual foundations and in the strategies used to attain these goals. Cultural training models in the field of mental health may be based on the approach of social constructivism (13) or the notion of cultural empathy (15) as well as the Cultural Formulation (16). They implement a myriad of different training techniques, such as didactic approaches (17), structured exercises (18), narrative analysis (19), experiential learning (16, 20) or cultural immersion (21).

Despite the abundance in cultural competence training models, there is surprisingly little data on their effectiveness. A recent systematic review of models for cultural competence training in the health professions identified that out of 109 publications that presented such models, only nine, and all from the U.S., included an evaluation (22). The findings generally indicate positive effects for cultural training (6, 23, 24). However, only currently, the first steps were taken towards the development of a more systematic approach to evaluating cultural competence training programs (25).

To sum up, there is a growing understanding that mental health services need to be more culturally attuned. Although cultural competency has been defined in many different ways, the widest common conceptualization is that it comprises knowledge, awareness and skills with regard to the differences and similarities between the culture of the client and the mental health professional.

Although Israel is typified by an almost constant influx of new immigrants and numerous ethnic groups, little has been done in the country to promote culturally228

sensitive practice or mandate the inclusion of cultural training in the educational curricula of mental health professionals. Only recently, the importance of providing culturally-sensitive care was acknowledged with the Ministry of Healthâ&#x20AC;&#x2122;s call for action (26). On the individual level, numerous practitioners and researchers working in Israel integrate cultural components in their work (27-40). Yet, no collective and systematic effort has been made to formulate standards for culturally-informed practice and training in the field of mental health.

This paper hopes of contribute to this effort by raising the awareness to the need and feasibility of culturalcompetence training in Israel. It presents a successfully applied training model for cultural competence and the results of an evaluation study of the effects of this training.

This paper illustrates the application of the training model to the encounter of practitioners from the majority group (i.e., Jewish Israeli natives) with Jewish immigrant clients.

However, its principles and techniques can be applied to culturally-competent practice with clients from other minority groups in Israel, and in other countries.

The Training Model Aims and rationale

The training model being evaluated in this paper has been described in detail in an earlier publication (41) and will be presented here briefly. Its primary aim is to help students develop empathy towards clients from various cultural backgrounds, and especially to those whose background is different than their own. In the present context, attention is devoted to becoming aware and attuned to the clientsâ&#x20AC;&#x2122; experiences as immigrants, as newcomers to a foreign culture and/or as members of a minority group.

An attempt is made to educate clinicians to adopt a humble stance that takes into account their own subjectivity and cultural biases and keeps them under continuous self-scrutiny. The training model also underscores the importance of cultural information and culturally-attuned skills. It offers some information on major ethnic groups in Israel and encourages ongoing cultural knowledgeseeking and skills development.

Two assumptions dictated the techniques implemented in the model to achieve those aims: First, personal narratives are a major source of information and knowledge about the experience of people in different cultures. Because they are flexible and narrator-oriented, narratives can contain unique cultural materials and help trainees become more aware of the uniqueness

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of each culture, as well as of the specific expressions of universal values and personal characteristics in different cultures (42, 43). The analysis of narratives is based on the notion that sense-making is an interactive human activity (44). When trainees are active participants in the sense-making process, learning may result in greater self-awareness, which may become the ground for greater empathy and sensitivity to the other (19).

This assumption is the basis for the use of narratives and narrative analysis in the training model.

Second, cultural training comprises not only the acquisition of knowledge and skills, but also emotional learning and self-awareness. The encounter with clients from a different culture, whose experiences as immigrants, refugees or members of a social minority are unfamiliar to Western practitioners, may stir in them a myriad of intense, often unconscious, emotions. Unconscious resistance against the awareness of these experiences may obstruct the learning process (43). Therefore, to clear the way for the acquisition of knowledge and skills necessary for culturally-competent practice, a training model needs to address unconscious resistance, attitudes and beliefs of the trainees, and develop their self-awareness and empathy towards the “other.” This assumption leads to the use of the group process.

Setting and techniques

The training model is implemented in a course that has been taught by the author for the past seven years in the Master’s program of Social Work at the BenGurion University. It is an elective course open to MA and PhD students in Social Work and Psychology, and is most often attended by students currently working in the field of mental health or those interested to become mental health professionals. The course consists of 48-50 academic hours offered over one or two semesters with weekly sessions. On average, 24-26 students participate in the course yearly.

The course combines two interweaving elements.

First, presentation and discussion of scientific articles on psychological aspects of migration. Second, an analysis of immigrant’s narratives. The scientific materials include the state of art theoretical and research articles on individual and family processes in migration, stress, coping strategies and psychopathology, as well as clinical papers on interventions with clients from diverse cultural backgrounds and on counter-transference with such clients. The narratives are collected by students through in-depth, unstructured interviews with peo-

ple who experienced migration or cultural transition.

Typically, students interview their friends, neighbors, co-workers and relatives. To avoid the effect of preexisting relationships on the interview, students are encouraged to interview the friends or co-workers of other students. The interviews are tape-recorded and transcribed. Each student submits a paper based on the analysis of the narrative of his/her interviewee and the relevant literature. Some students also present their interviews in class. This is followed by a class discussion, with of the course instructor acting as a facilitator.

Gaining empathy – the group processes

The following process extracts illustrate how the group work helps the participants gain empathy towards the interviewees: Vignette 1

Gregor, a 67-year-old man, immigrated to Israel from Yugoslavia as a child, a number of years after World War II. Upon arrival, his parents sent him to a boarding school, where he was the youngest in his group. There he became the target of mockery and bullying. He succeeded in becoming a “model Israeli” and in erasing his past: “I don’t remember anything from before the age of 12, my memory starts when we got to Israel.” Gregor told his story in a dry tone and a number of times repeated: “I have no hard feelings.”

The interviewer was very emotional when he presented the narrative in class.

He was surprised at his own reaction because during the interview with Gregor he was not that moved. Similar reactions followed from other students. They captured the covert sadness of Gregor, his denial of it and his determination to cope at any cost. Explorative group process allowed uncovering the emotions that accompanied Gregor’s adjustment as an immigrant, emotions of which he himself was not aware. The insight that the participants, including the interviewer, who had known Gregor for many years, gained into Gregor’s denied emotions made it possible for them to feel more empathy towards him.

Vignette 2

Diana, 30, married with two children, emigrated from the former Soviet Union in her late teens. Her mother abandoned her in childhood and she was raised by her maternal grandparents in a city distant from where she was born.

Following the war in Chechnya, the family fled to another region and then to Israel. Her elderly grandparents died a 229

In Praise of Cultural-Competence Training for Mental Health Professionals

few years after they arrived and she remained alone. For a number of years Diana supported herself by selling her body to men and earned a lot of money. After having been seriously injured in a car accident, she decided to change her lifestyle. Presently, she pursues a successful career and raises a family. However, she does not feel she belongs in Israel and appears emotionally detached.

The following discussion took place in class after Diana’s interview was presented: (MU): This is the saddest story we have heard this year.

(SA): Nothing ties her to anywhere (AA): So horrible, a child abandoned by her mother (OH): The detachment is very obvious: one is born in one place, lives in another, dies in yet another…

(TA): Terrible things happen to her all the time, they just drop on her and there is nothing she can do, sometimes only flee.

(SA): Yes, she is detached, feels nothing, loves no one.

And she has everything, a family, children, a home.

But she feels differently.

(Facilitator): Maybe this is how she feels because many of the things she used to have were “taken” from her - by chance, by accident - things that are important to her she loses.

(AA): She had her body, this could not be taken from her and she could sell it and get money.

(YK): She did not have much choice but to sell her body.

(AA): It was not a free choice.

(MR): My grandmother went through the Holocaust, it was worse, and she did not… It annoys me when you say “she did not have a choice.” She chose to be detached and miserable, she keeps choosing that.

(AL): She is not miserable, she is detached.

(Facilitator): It is important to try and understand what is annoying in Diana’s story.

(MR): I am sorry, I was being judgmental, but…

A fervent discussion arose in class as to whether she did or did not have a choice and I, the facilitator, interpreted this as a sign of difficulty and resistance: (Facilitator): Perhaps it is difficult for us to realize, that although we have choices, there are also constraints in our lives. The personal assets that we possess determine our choices, especially in stressful situations. Her personal assets and external conditions considered, Diana must have made the best choices she could possibly make.

(SA): Yeh, she is a very strong woman. I don’t know how I would have coped in her place…

Others nodded in agreement.

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The evaluation study The following is qualitative evaluation study that was performed two months following the termination of three consecutive courses.

Respondents. The respondents were 51 students from three academic years, representing between 70% and 85% of all students who participated in the course each academic year. Most students (80%) in the evaluation study were women and this reflects the gender profile of social work students as well as practitioners. Most (80%) were in their late twenties to early thirties, with only few exceptions (two students were aged 47). One-fourth (25%) of the students were foreign-born, all from the former Soviet Union. Half (50%) were second generation immigrants [although they did not initially identify themselves as such but rather as “Sabra”]. One-fourth (25%) of the respondents were third or fourth generation, among them six Arab and Bedouin students.

Data collection. The students were asked to submit a short account (200-500 words) of their personal experience in the course (an elective assignment). The instructions were as follows: “Please, relate to your personal experience in the course: Your experiences in the interview; How did your participation in the course affect your attitudes towards clients from diverse cultural backgrounds? Towards yourself? These are merely general guidelines. Feel free to share whatever you find significant.”

The accounts of 51 respondents who submitted this elective assignment comprised the data of the qualitative evaluation. These accounts were submitted about two months after the end of each course.

Data analysis. The contents of the accounts were analyzed by the author via a holistic method (45). First, all accounts were read several times with the aim of obtaining a general orientation on the presented contents.

“Open coding” applied in the next round of reading, made it possible to code central themes within each of the accounts, and accompany them by citations from the account. In the next readings, themes that reoccurred in several accounts were identified. Then “axis coding” was applied: the recurring themes were defined more precisely and more clearly differentiated from each other. The final reading of all accounts made it possible to fine-tune the themes and select the most illustrative citations.

Findings. The following findings relate to the cognitive outcomes of the training – What information did the students acquire in the course? What did they learn? -

Julia Mirsky

and to practical outcomes – How did this learning affect the students’ practice? These two outcomes emerged as central themes in data analysis. An additional theme, the personal and emotional outcomes of the training, is not addressed here due to lack of space. Extracts from representative accounts by respondents accompany presentation of major themes.

A. Cognitive outcomes of training All respondents related in their accounts to the fact that they gained significant knowledge in the course. Many did that through general statements such as “I gained a lot of knowledge about migration in the course” or “the course contributed to my understanding of immigration and immigrants.” Also, 26 respondents (51%) related to this issue explicitly and in detail. The knowledge\understanding they referred to can be grouped into three categories: A.1. Understanding of the significance of the experience of migration Most striking in the accounts was the fact that only following the course did many of the respondents begin to understand how significant the experience of migration may be in a person’s life. In the words of one of the respondents - “how present” it is.

(OH) I take with me the appreciation that immigration is a dramatic life situation that destabilizes the emotional balance in all spheres of life, and that it should be taken very seriously.

(TA) Now, I understand better the power of the experience of migration. It is an important and significant event in the life of a person. It influences the person’s future life and is an inseparable part of his/her personality, of the way the person deals with the natural and common tasks of life.

A.2. Understanding of the universal psychological nature of migration Many respondents reported that they gained an understanding that they did not have before about the psychological processes that occur during migration and cross-cultural transitions: (AA) I learned about the impact of migration on the individual and the family, and of how important it is to understand it.

(YK) I gained new insight into the processes of migration on the theoretical level, mainly psychological – about processes that are universal and that immigrants experience them wherever they are.

Even respondents who underwent migration gained deeper insights into the impact of migration: (MU) My participation in the course made me very much aware, which I was not before although I am an immigrant and came to Israel 20 years ago, to the multiple meanings and complexities of migration.

Most of the respondents stressed their newly gained awareness of the negative implications of migration: (SZ) … the difficulties immigrants have: the difficulty to get used to a new culture, the mourning of what has been left in the homeland, the question of belonging: to which country do I belong now?

(AL) … I learned to understand that the transition from one country to another, even if it was voluntary and driven by ideals, may be very difficult.

(TH) The course helped me to understand how immigration difficulties may add to the normative stresses of adolescents and render adolescent immigrants at special risk.

However, some respondents managed to develop a more balanced view of the impact of migration: (LP) … the experience of migration is complex: it is exciting, interesting, challenging but also frightening, worrying and stressful.

(MB) I came out with the understanding that migration is a universal event that holds unique difficulties as well as unique opportunities.

A.3. Understanding the uniqueness of the experience of migration Along with the understanding of migration as a universal psychological process, the respondents emphasized the individual diversity and unique quality of each person’s migration experience.

(RM) There is not one constant process that each immigrant goes through and there is not one narrative with similar main themes that all immigrants have.

(SA) I understand how the process of immigration is on one hand common to many immigrants. But, how on the other hand, it is very personal and differs in each family. Most immigrants experience more or less similar events that have to do with migration: low status and low paid jobs, learning a new language, moving from one rented apartment to another. But each immigrant arrives with different assets, material and emotional.

(AA) The experience is different and unique for each individual…. I understand now the decisive impact of personal and psychological assets in the process of 231

In Praise of Cultural-Competence Training for Mental Health Professionals

migration. …. the importance of the psychological personality structure of the immigrant, of family relationships, of the age of migration. These factors decide whether the outcome will be a success or a failure.

B. Effects of training on practice Perhaps, because all students in the course were working in the field, more respondents related in detail to the implications of the course to their practice than to purely cognitive outcomes of the training. In addition to general statements such as “the course changed my attitude to clients” or “I feel that my practice with immigrant clients will be better now,” 29 respondents (57%) provided detailed accounts of the effect the course had on their practice.

B.1. Exploration of the migration experience with clients The cognitive understanding that migration has important and long-term implications in all spheres of individual life was translated by many of the respondents into a special attention to this issue in their professional practice. They kept the importance of this experience in mind and encouraged their clients to talk about it: (ST) I give space to my client’s immigration story even if immigration took place long ago and seems not to be related to his/her present condition.

(AR) The course taught me that we need to make it possible for our clients to get in touch with their pain and their unpleasant memories, but also become aware of the growth and other things they gained because of immigration.

The following clinical vignette provided by one of the respondents vividly illuminates this outcome.

(MB) Working in an emergency center for children at risk I was treating a 33-year-old woman whose son was placed in the center. This client had immigrated to Israel when she was 14. As I got to know her better, parallel to taking the course, I started to appreciate the heavy weight of immigration in her development … and the scar she was still bearing from that time.

She was reluctant to talk about the crises she experiences as an immigrant, wanted to “let bygones be bygones” and was eager to “belong,” to be “an Israeli.”

I could have easily avoided the issue, like she wanted, had I not been aware of its importance. But, when I mustered the courage to bring it up, a whole array of experiences and emotions was revealed and became very significant to the success of this treatment.

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B.2. Taking immigration into account during assessment process Respondents mentioned the theoretical knowledge they acquired about the process of migration that guided their assessment of their clients: (OB) I try to understand in what developmental stage they experienced migration, what are the unresolved remnants of this experience, what developed into a trauma, and in what way the immigration experience is reflected in the therapeutic relationships.

(IE) I am working with foster families and many of the children we send to foster care are immigrants. The course made me aware of the effect of immigration on the reality of life of families and how difficult it may be for immigrant families to understand their situation and cope with it. In staff meetings, in the reports that I write and in my direct encounters with clients, I now try to underscore issues related to migration as an inseparable part of the coping of the child and the family.

(TB) The ability I acquired in the course to see the connections between immigration processes and my clients’ health helps me to gain the cooperation of clients and staff… I often share my understanding with our inter-disciplinary team in order to help them connect to the world of their immigrant clients.

Again, most impressive is the testimony of respondents who have themselves experienced immigration as illustrated in the following quote: (MB) I must admit that although I immigrated at the age of 14, the course opened my eyes to the fact that the experience of immigration is a crucial aspect of my clients’ lives.

B.3. Empathy The above illustrations imply that the respondents gained more empathy in relationship to their immigrant clients. Some respondents mentioned this outcome overtly: (SN) I have now a more sensitive view of my clients’ complex reality.

(NY) When I put on my “new glasses” that I gained in the course, I can see my clients in a more sensitive way.

(TB) The comprehensive understanding of immigration and the psychological processes that accompany it made me able to create deeper and more containing relationships with my clients.

B.4. Recognizing and respecting cultural diversity The extension of empathy seems to be the respondents’

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greater awareness and tolerance of the “otherness” of their immigrant clients. Although mentioned only by few as a purely cognitive outcome, cultural sensitivity and respect for their clients’ cultural background permeated many accounts of professional practice: (KZ) In this course I acquired tools that will help me to calibrate my therapeutic sensitivity towards immigrant clients, to understand and respect the norms they brought with them from their homeland.

(OA) Recently, I worked with an immigrant family where the mother was very dominant and the father rather passive. This mother was also very worried about her adolescent daughter, although the situation of this girl in comparison to her native-born peers was really good. The mother was saying the “there” things were different than “here” and there were many clashes in communication between her and her “Israelized” daughter. I was so happy that I took the course and all this was clear to me.

Several respondents who expressed similar ideas via self-criticism: (NM) I grew to understand that we, social workers, are often patronizing in our interventions with immigrants and perpetuate the stresses that immigrants experience. When, without understanding the immigrants’ world, we demand that they adjust to the society we live in and pressure them to abandon their homeland culture, we may be perpetuating their distress.

One of the respondents describes in detail the change that she experienced in her practice following the course: (MS) Before I took the course I was aware of the cultural diversity of my clients and of their different behavioral patterns and belief… However, this was merely “information” and once I entered the clinic, I chose to put this information aside. Instead I used to cling to familiar patterns, theories and therapeutic tools, which mostly apply to western cultures without ever testing their applicability to my clients’ cultural background. Now, I am more aware of the link between my clients’ cultural background and my ability to provide them with an appropriate service, with empathy, with a non-judgmental and non-prejudiced attitude… this strengthens my empathy and the therapeutic relationship. This awareness now puts me in the position of constant exploration of my own cultural patterns, norms and values.

Conclusions Although it has been recognized that cultural competence is an essential component of training mental health professionals, there is surprisingly little research evidence that such training is effective ( 22). This study, which evaluated the outcomes of cultural-competence training, contributes to the limited body of research in this area. The findings consistently indicate that the training course had meaningful outcomes. On the cognitive level, students acquired insight into the centrality of immigration in the lives of individuals and families and the long-term ramifications of migration.

They also gained understanding as to the psychological processes typical to the transition from one country, or culture to another. Parallel to getting familiar with universal processes in migration, students learned to appreciate the remarkably unique nature of the migration experience. This cognitive enrichment appeared to have influenced the students’ practice with clients from diverse cultural backgrounds. They became more attentive to the experience of migration in their clients’ lives, and addressed it in their communication with clients, in assessment of clients as well as with their colleagues.

They reported that they became more empathic to their clients’ experiences and difficulties and more tolerant and respectful of the cultural diversity among their clients.

The present study has several limitations. The qualitative methodology with a relatively small number of respondents, obviously limits the power of generalization of the results, as does the short-term of the evaluation that cannot reveal the long-term effects of the training. The fact that the evaluation is based on the subjective accounts by the trainees themselves is also a limitation. Similar limitations applies to most research on cultural competence, qualitative as well as quantitative, as most instruments in this field are self-report measures (25). The fact that the data were analyzed by one person is another limitation as no inter-rater reliability check was feasible. A quantitative research methodology, and especially with a control group design, would provide more robust data on the effects on practice following cultural training.

The training model and the evaluation were presented here with the hope to demonstrate the potential contribution of cultural-competence training to improving clinical practice and services for a diverse client population.

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Int Soc Work 1999;42:347-358 33. Bilu Y, Witztum E. Working with Jewish ultra-orthodox patients: Guidelines for a culturally sensitive therapy. Cult Med Psychiat 1993;17:197-233.

34. Dwairy M. Toward psycho-cultural approach in Middle Eastern societies.

Clin Psychol Rev 1999; 8:909-915.

35. Grisaru N, Budowski D, Witztum E. Possession by the “Zar” among Ethiopian immigrants to Israel: Psychopathology or culture-bound syndrome? Psychopathology 1997;30:223-233.

36. Grisaru N, Irwin M, Kaplan Z. Acute psychotic episodes as a reaction to severe trauma in a population of Ethiopian immigrants to Israel. Stress Health 2003;19:241-247.

37. Jaffe ED. Ethnic and minority groups in Israel: Challenges for social work theory, values, and practice. In: Weiner E, editor. The handbook of interethnic coexistence. London: The Abraham Foundation, 1998: pp. 585599.

38. Lavee Y. Family therapy in a multicultural society: The case of Israel. In: Kit S, editor. Global perspectives in family therapy: Development, practice, and trends. New York, N.Y.: Brunner-Routledge, 2003: pp. 175-194.

39. Roer-Strier D. Reducing risk for children in changing cultural contexts: Recommendations for intervention and training. Child Abuse Neglect 2001; 25: 231-248.

40. Youngmann R, Zilber N, Workneh F., Gill R. Adapting the SRQ for Ethiopian populations: A culturally-sensitive psychiatric screening instrument. Transcult Psychiatry 2008;45:566-589.

41. Mirsky J. The use of narrative analysis and psychoanalytic exploration of group processes in multicultural training. J Appl Psychoanal Stud 2008;5:215.

42. Peterson JA, Van Meir E. Using patient narratives to teach psychopathology.

J Marital Fam Ther 1996; 22:59–68.

43. Lijtmaer R. Strategies for coping with resistances in teaching multicultural courses. Paper presented at the 48th American Academy of Psychoanalysis and Dynamic Psychiatry Conference: New York City, April 2004.

44. Glanz L. Expatriate stories: A vehicle of professional development abroad? J Manage Psychol 2003;18:259–274.

45. Lieblich A. The holistic-content perspective. In: Lieblich A, Tuval-Mashiach R, Zilber T, editors. Narrative research: Reading analysis and interpretation.

Thousand Oaks, Cal.: Sage, 1998: pp. 62-87.

Book Reviews

Book reviews Suicide in Israel. Suicides, 1981-2009. Suicide Attempts, 2004-2010 Editors: Goldberger N, Aburba M, Haklai Z. Information and Computer Services, Division of Information, Ministry of Israel, State of Israel. November 2011, pp. 83. www.health.gov.il/suicides.

T

his is an updated and rich report on both components of suicidal behavior, of interest to researchers, clinicians, decision makers and public in general.

It comes close in time to the first evaluation of a pilot community-based program purported to reduce suicidal behavior in three localities in Israel (cf. Haaretz, December 2011). Although completed suicide is relatively low in Israel (it ranks second lowest, for women, and third lowest, for men of a list of 27 European Union countries), as informed by this report, national authorities are pursuing comprehensive preventive actions to reduce the rates even further, particularly among vulnerable population groups for all suicidal behavior, e.g., the new immigrants (1, 2), the elderly, the young (3), those who were abused in childhood (3), or Holocaust survivors (4). A comprehensive review of Israeli epidemiologic studies was coauthored by Bursztein and Apter (5).

As the title states it, this report has two sections, one on completed suicide, covering the years 1981-2009 (with nine sections, pages 11-59) and on suicide attempts, covering the years 2004-2010 (with seven sections, pages 63-83). The former is based on the national database on causes of death and the latter, on contacts with the 28 hospital-based emergency departments solely. This review addresses both sections independently.

Completed suicide The authors inform us that despite intensive efforts to ascertain suicide, resulting from its negative social sanction, some completed suicides may appear in the mortality database as undetermined external causes of death.

For this publication, the authors have made corrections following the examination of all available evidence, but a residue of unavoidable undetermined causes might lead the researcher to estimate rates and risks of suicide without and with these causes. However, this type of updated published information is yet to be made available.

There is much to learn in this report. The following is

merely a selective sample of issues purported to awaken the curiosity of potential readers to examine the report in its entirety..

First thing to learn is that the age-adjusted rates (as they are reported throughout) have decreased from the highest in 1989, 12.0, to 7.4, in 2009, both per 100,000 population. This decrease has been observed in both genders and in all age groups. (Some fluctuations have occurred over the years, but the tendency remained preserved.)

The report indicates the existence of rate differentials, as follows: Gender: Men are twice more likely to commit suicide, men,s rate: 7.4, women,s rate: 3.3, both for 100,000 population, for the year 2009.

Age: As the age grows older so do the rates of suicide.

The old-old (75 years and above) are at the highest risk, a pattern that has shown to be stable from 1982 to 2008, in both genders. Note, however, that the numbers of suicide of this group is small, 31 (or 7.7%) of the total of suicides for all the population (N=404), for the year 2009. For the men 75 years and above, their suicides represent 74% of all the absolute number of suicides of this age group, far above their proportion in the general population.

Arab-Israelis/Jewish Israelis: A constant rate differential, always higher among the latter group, has been found over the years. The rate ratio between both groups reached 2.4 in 2008. A recently published article addressed this interesting finding (6). Of no less interest is that the rate ratio varies by age group.

Immigrants: This publication calls attention to the higher rate ratio of suicides committed by Jewish immigrants as compared to the local born. This finding, that was identified in the past (7), repeats itself with the more recent immigrants from the former USSR (1) and Ethiopia (2). Because of the small numbers among women, the finding is more salient among men, and it is present in all age groups.

Marital status: Groups present a different risk, which differs by age group. Among the younger groups (2544) the rates are higher for the divorced, followed by the single and markedly smaller for the married. However, in the age group 45-64 the report notes that the first place is reversed, it is higher for the single, while the divorced rate is the one that follows. The latter finding is more visible among men.

Locality: As expected from the above, rates vary by localities. As expected as well, the lowest rate is found in Jerusalem, where religiosity could be identified as a 235

Book Reviews

protective factor. A pending challenge is to account for the factors responsible for the higher reported rates in localities such as Hedera, Beer Sheva, Akko and Heifa.

Means of suicide: The report brings information on the different means used by gender and age group. For example, 3% of men used poisoning in contrast to 9% of women, while 17% of the former used firearms in contrast to 5% of women.

Seasonality: Suicides rates are higher in winter and lowest during the seasons of the High Holidays and Passover.

Suicide attempts Numbers are high, in 2010 alone there were 5,640 attempts. During the years 2004 to 2010 the rate for men was 70-76 while for women it reached 102-108.

For both genders, the rates are for 100,000 population aged 10 and above.

Arab-/Jewish-Israelis: The report provides information on the attempts by age groups and gender, as well separately by Arab- and Jewish-Israelis, highlighting the differential risks, and over time.

With regard to the majority-minority division, the report shows information that clearly contrasts with completed suicide. With regards to attempts, the difference between the two groups is considerably less.

New immigrants: The other minority on which information is reported refers to the new immigrants. As in suicide, the risk is higher among them in contrast to the Jewish population that is local-born or whose immigration took place years back.

Localities: As in suicide, there are differences by localities, but they do not mimic their ranking according to rates.

Seasonality: Attempts varied by month and by the day of the week. The summer months were those of higher risk while Sunday is the day when those who attempt, both men and women, turned to the hospitals for help.

Admission to hospitals: This may constitute a proxy measure of the seriousness of the attempt. The report shows that for the years 2006 to 2010, 56.1% of the contacts ended with admission.

236

In a publication with so many peaks as this one it is difficult to find valleys. Perhaps there is a visible one: no information has been provided on suicides by ethnic groups among Jewish-Israelis. One is curious to learn whether the pattern of higher rates among Ashkenazi Jews in contrast to Oriental Jews remain, as it had been noted in the past (7).

Lastly, the publication deserves a brief complementary comment about its format, it is highly user-friendly.

Also, the text that accompanies the illustrations is clear, concise and pertinent, and of easy understanding by professionals and not professionals alike. Another bonus is that the tables and graphs could easily be adopted for teaching and advocacy meetings.

Itzhak Levav, Jerusalem

References 1. Mirsky J, Kohn R, Dolberg P, Levav. I. Suicidal behavior among immigrants. Soc Psychiatry Psychiat Epidemiol, 2010; 46: 11331141.

2. Shoval G, Schoen G, Vardi N, Salzman G. Suicide in Ethiopian immigrants in Israel: a case forstudy of the genetic-environment in suicide. Arch Suicide Res 2007; 11: 1-7 3. 3. Farbstein I, Dyclan A, Gothelf D, King R , Cohen D , Kron Sh, Apter A. A follow up study of adolescent attempted suicide in Israel. J Am Acad Child Ad Psych 2002 41 1342-1349.

3. Levav I, Gross R. Prevalence and long-term effects of child abuse in Israel. Findings of the National Mental Health Survey.

Society and Welfare. 2010; 30: 359-376 (Hebrew).

4. Barak Y, Aizenberg D, Szor H, Swartz M, Maor R, Knobler H. Increased risk of suicide attempt among amongst aging Holocaust survivors Am J Ger Psych 2005; 13: 701-704.

5. Bursztein C, Apter A The epidemiology of suicidal behavior in the Israeli population in Levav I (ed). Psychiatric and behavioral disorders in Israel. From epidemiology to mental health action, Gefen, Jerusalem 2009.

6. Gal G, Goldberger N, Kabaha A, Haklai Z, Geraisy N, Gross R, Levav I. Suicidal behavior among Muslim Arabs in Israel. Soc Psychiatry Psychiatr Epidemiol. 2012; 47: 11-17.

7. Levav I, Aisenberg E. Suicide in Israel: crossnational comparisons. Acta Psychiat Scand, 1989; 79, 468-473.

‫ישיבת הוועד המרכזי של האיגוד‬ ‫ספטמבר ‪2012‬‬

‫‪1 .1‬לוועד המרכזי צורפו‪ ,‬כמשקיפים‪ ,‬נציגי השירותים‬ ‫האמבולטוריים‪ .‬הצרכים והקשיים הוצגו‪ ,‬וסוכם כי‬ ‫הסוגיות הדורשות מעורבות של הוועד יגובשו לקראת‬ ‫המפגשים הבאים‪ .‬ייערך כנס של האיגוד בנושא איכותו‬ ‫והספקתו של הטיפול בקהילה וישתתפו בו מנהלי‬ ‫השירותים בקהילה‪.‬‬ ‫‪ 2 .2‬הוצגו העקרונות להעברת שירותי בריאות הנפש בקהילה‬ ‫‪1‬לקופות‪:‬‬ ‫‪1‬א‪ .‬כל השירותים ימשיכו להיות באחריות המדינה (לפי‬ ‫‪1‬התוספת השלישית לחוק) עד ‪ - 1.1.2015‬לתקופת ביניים‪.‬‬ ‫‪1‬ב‪ .‬אופי וסטנדרט השירות הקיים יימשכו‪.‬‬ ‫‪1‬ג‪ .‬הקופות יהיו ספקיות שירות והן יפתחו את השירותים‬

‫‪ 1‬בקהילה על פי תכנית שתאושר ותתוקצב בתקופת‬ ‫‪ 1‬הביניים‪.‬‬ ‫‪1‬ד‪ .‬כל שירותי בריאות הנפש הניתנים כיום על ידי המדינה‬ ‫ימשיכו להינתן למטופלים‪.‬‬ ‫‪3 .3‬אושרה העסקת מזכירה לשם טיוב מערך ההוצאה לאור של‬ ‫‪1‬עיתון האיגוד (‪.)IJP‬‬ ‫‪4 .4‬האזוריות בהספקת שירותי האשפוז תישמר‪ ,‬למעט בקשות‬ ‫חריגות שיאושרו על ידי מנהלי המרכזים‪ ,‬עד להורדת‬ ‫התפוסות באשפוז‪.‬‬ ‫‪5 .5‬האיגוד תומך בשינוי החקיקה לאשפוז כפוי של חולי אנורקסיה‬ ‫הנמצאים בסכנת חיים על רקע גופני בתנאים הנדרשים‬ ‫וביחידות המתאימות לכך בבתי חולים כלליים‪.‬‬

‫איגוד הפסיכיאטריה בישראל‪ :‬ההסתדרות הרפואית ‪ -‬המועצה המדעית ‪Israeli Psychiatric Association -‬‬

‫יו"ר‪ :‬פרופ' משה קוטלר ‪president: Prof. M. Kotler /‬‬ ‫‪Moshe.kotler@beerness.health.gov.il‬‬ ‫מזכיר כללי‪ :‬ד"ר טל ברגמן לוי ‪secretery General: Dr. T. Bergman–Levy /‬‬ ‫‪Tal.Bergman–Levy@beerness.health.gov.il‬‬ ‫גזבר‪ :‬ד"ר שמואל הירשמן ‪Treasurer: Dr. S. Hirschmann /‬‬ ‫‪shmuelhirschmann@yahoo.com‬‬

‫מרכז לבריאות הנפש באר יעקב‬

‫‪Beer Yaacov Mental Health Center‬‬

‫ ת‪.‬ד‪ 1 .‬באר יעקב‬ ‫‪Beer Yaacov Mental Health Center, P.O.B 1 ,‬‬ ‫‪Beer Yaacov, Israel, 70350‬‬

‫יו"ר נבחר‪ :‬פרופ' חיים בלמקר ‪/‬‬

‫‪Elected President: Prof. H. Belmaker‬‬ ‫‪belmaker@bgu.ac.il‬‬

‫יו"ר יוצא‪ :‬פרופ' זאב קפלן ‪/‬‬

‫‪President-Emeritus: Prof. Z. Kaplan‬‬ ‫‪Zeev.kaplan@pbsh.health.gov.il‬‬

‫ברכות והצלחה ליו"ר הנכנס‪ ,‬פרופ' קוטלר‪ ,‬ולוועד הנבחר החדש‪.‬‬ ‫תודה לכל החברים שתמכו ופעלו במהלך השנים המורכבות למערך הפסיכיאטריה בישראל‪.‬‬

‫ישיבת הוועד המרכזי של איגוד הפסיכיאטריה לישראל‬ ‫‪29/08/2012‬‬

‫נוכחים‪ :‬פרופסור משה קוטלר‪ ,‬ד"ר טל ברגמן לוי‪ ,‬ד"ר שמואל הירשמן‪ ,‬פרופסור חיים בלמייקר‪ ,‬פרופסור זאב קפלן‪,‬‬ ‫‪1‬פרופסור יובל מלמד‪ ,‬ד"ר בוריס נמץ‪ ,‬ד"ר נמרוד גריסרו‪ ,‬ד"ר צבי פישל‪ ,‬ד"ר מרנינה שוורץ‪ ,‬ד"ר בן עמית‪ ,‬ד"ר עדי דורון‪,‬‬ ‫ד"ר אנדרי דרבינסקי‪ ,‬ד"ר אלכס טייטלבאום‪ ,‬פרופסור דב אייזנברג‪ ,‬פרופסור יורם ברק‪.‬‬ ‫משקיפים‪ :‬ד"ר יעל נחמה‪ ,‬פרופסור חגי חרמש‪ ,‬ד"ר איגור ברש‪.‬‬ ‫עיקרי הדברים‪:‬‬ ‫‪1 .1‬אושר תפקידה של ד"ר טל ברגמן לוי כמזכירה כללית של איגוד‬ ‫הפסיכיאטריה בישראל‬ ‫‪2 .2‬אושר תפקידו של ד"ר שמואל הירשמן כגזבר כללי של איגוד‬ ‫הפסיכיאטריה בישראל‬ ‫‪3 .3‬אושר מינויים של יושבי ראש ועדות האיגוד ‪:‬‬ ‫שם הוועדה‬

‫יו"ר הוועדה‬

‫ועדת האתיקה‬

‫פרופסור יובל מלמד‬

‫ועדת חוק ומשפט‬

‫ד"ר אלכס גרינשפון‬

‫ועדת ניירות עמדה‬

‫פרופסור חיים בלמייקר‬

‫ועדת הוראה והתמחות‬

‫פרופסור חיליק לבקוביץ‬

‫ועדת בחינות‬

‫פרופסור שמואל פניג ‪ +‬ד"ר צבי‬ ‫פישל ‪ +‬ד"ר בוריס נמץ‬ ‫** העברת אחריות הדרגתית תוך‬ ‫ביצוע חפיפה‬ ‫ד"ר פישל ‪ -‬יהיה אחראי על‬ ‫בחינות שלב ב'‬ ‫ד"ר נמץ ‪ -‬יהיה אחראי על בחינות‬ ‫שלב א'‬

‫ועדת ביקורת‬

‫ייקבע בהמשך (בהתאם לנוהלי‬ ‫תקנון)‬

‫ועדת תקשורת ומיתוג‬

‫ד"ר שמואל הירשמן ‪+‬ד"ר טל‬ ‫ברגמן לוי‬

‫ועדת נסיעות‬

‫ד"ר נמרוד גריסרו‬

‫ועדת פרסומים מדעיים‬

‫פרופסור יורם ברק‬

‫נציגת ועדת הכרה‬ ‫להתמחות בהסתדרות‬ ‫הרפואית‬

‫ד"ר מרנינה שוורץ‬

‫נציג הפסיכיאטריה של‬ ‫הוועד הפועל של המועצה‬ ‫המדעית של הר"י‬

‫ד"ר נמרוד גריסרו‬

‫ועדת סניורים‬

‫ד"ר מיכאל שניידמן‬

‫‪4 .4‬נוהלי מינוי יו"ר ועדת הביקורת של האיגוד ייבדקו ע"י ד"ר‬ ‫ברגמן מול ההסתדרות הרפואית‪ ,‬ועדת הביקורת תמונה‬ ‫בישיבת הוועד הבאה‪.‬‬ ‫‪5 .5‬ועדת האתיקה של איגוד הפסיכיאטריה תדון בעניינם של אנשי‬

‫מקצוע ובנושאים הקשורים למקצוע הפסיכיאטריה‪ .‬פרופ' יובל‬ ‫מלמד יגבש ועדת אתיקה בלתי תלויה‪ .‬האיגוד יידע את ההסתדרות‬ ‫הרפואית כי ענייני הפסיכיאטרים חברי האיגוד יידונו במסגרת ועדה‬ ‫זו תוך שימוש בנורמות ובאמות מידה של האתיקה המקצועית של‬ ‫תחום הפסיכיאטריה‪ .‬נורמות ואמות מידה אלו‪ ,‬כמו גם עקרונות‬ ‫האתיקה המקצועית של הפסיכיאטריה‪ ,‬ייקבעו ע"י האיגוד‬ ‫המקצועי היציג של התחום ‪ -‬איגוד הפסיכיאטריה בישראל‪.‬‬ ‫‪6 .6‬אושרה הקמת קבוצת עמיתים בתחום התחלואה הכפולה‬ ‫במסגרת האיגוד‪ .‬על קבוצה זו לפרסם את קיומה וכן לאפשר‬ ‫הצטרפות של כל חבר איגוד הרוצה בכך‪.‬‬ ‫‪7 .7‬הוצג פרויקט שבוע בריאות הנפש בחסות אגף בריאות הנפש‬ ‫במשרד הבריאות ליושבי ראש הסניפים‪ ,‬ובהמשך לשאר חברי‬ ‫הוועד‪ .‬נערך דיון בנושא‪ .‬חברי הוועדים מבקשים לקבל פרטים‬ ‫נוספים על התכנית המוצעת לרבות חברת ההפקה שתקדם את‬ ‫האירוע‪ ,‬מידת הגמישות בהפקת האירוע הסניפי ופרטים על מרצים‬ ‫נוספים שאינם פסיכיאטרים‪ .‬חברי הסניפים הציעו כי הרצאה אחת‬ ‫מתוך השלוש לציבור הרחב תעסוק בנושא דיכאון ושתי ההרצאות‬ ‫הנוספות יציגו תחומים נוספים בפסיכיאטריה‪.‬‬ ‫‪8 .8‬הוצגה הצעה של הנהלת האיגוד לשכור למשך שנה חברת‬ ‫יח"צ ומיתוג אשר תנהל תיק עיתונות לאיגוד ומשברים‬ ‫תקשורתיים וזאת על מנת להעצים את מעמד הפסיכיאטריה‬ ‫בישראל‪ .‬הנהלת האיגוד הבכירה ‪ -‬יו"ר‪ ,‬מזכ"ל וגזבר‪ ,‬הוסמכו‬ ‫ע"י הוועד המרכזי לבחון הצעות מחברות יח"צ שונות‬ ‫ולהחליט על החברה הנבחרת‪ ,‬תוך שימוש בקריטריונים‬ ‫ברורים‪ ,‬ותוך שימת לב לנושאי ניגוד אינטרסים‪.‬‬ ‫‪9 .9‬התקבלה בקשה לתמיכה כלכלית בכנס ‪ WPA–TPS‬העוסק‬ ‫בפסיכיאטריה רב תרבותית ‪ -‬נובמבר ‪ .2012‬מארגני הכנס יעבירו‬ ‫להנהלת האיגוד מפרט אשר יכלול את תכני הכנס ועלויות הכנס‪,‬‬ ‫דמי רישום וכו'‪ .‬המפרט יועבר לעיונם של חברי הוועד המרכזי‪.‬‬ ‫תתקיים הצבעה "אלקטרונית" חברי הוועד המרכזי יתבקשו‬ ‫להעביר עמדתם בנושא באמצעות דואר אלקטרוני למזכ"ל האיגוד‪.‬‬ ‫‪1010‬הוחלט לעודד השתלבות של מתמחים בפסיכיאטריה באיגוד‬ ‫ מתמחה שיירשם עד תום דצמבר ‪ 2012‬כחבר באיגוד‬‫הפסיכיאטריה ישלם דמי חברות לשנה עבור שנתיים של‬ ‫חברות (תשלום עד סוף שנת ‪ 2012‬עבור שנת ‪ ,2012‬תזכה‬ ‫בשנת חברות נוספת לשנת ‪.)2013‬‬

‫בברכה‪ ,‬הנהלת איגוד הפסיכיאטריה‪.‬‬

‫חברתית חלשה הפוגשים מטפלים השייכים לקבוצה חברתית חזקה‪.‬‬ ‫עם זאת‪ ,‬המנגנונים האחראיים לקשר בין הבדלי זהויות לבין פערים‬ ‫בבריאות אינם ידועים‪ .‬בהתבסס על מחקרים מתחום הפסיכולוגיה‬ ‫החברתית‪ ,‬אנו מתווים מודל שמטרתו לסייע בזיהוי המנגנונים‬ ‫הללו‪ .‬אנו סוקרים את הספרות על תהליכים הנובעים מקטגוריזציה‬ ‫חברתית (הטיית קבוצת החוץ) ומכוח חברתי (לקיחת פרספקטיבה‬ ‫לקויה‪ ,‬ייחוסים אוטומטיים)‪ ,‬ומציעים שהם עשויים להסביר מדוע‬ ‫זהויות חברתיות לא תואמות‪ ,‬לעומת תואמות‪ ,‬במפגשי טיפול‪,‬‬ ‫עלולות להניב תוצאות גרועות יותר‪ ,‬בכל הקשור לאיכות הקשר‬ ‫הטיפולי והדיוק באבחון‪ .‬אנו מספקים עדויות ראשוניות למודל‬ ‫המוצע ומציעים אג'נדה מחקרית‪ ,‬שמטרתה לספק מידע אמפירי‬ ‫לגבי התערבויות הקשורות להשלכות השליליות של מפגשי טיפול‬ ‫שבהם הזהויות החברתיות של המטפל והמטופל אינן תואמות‪.‬‬ ‫תגובות פסיכו־חברתיות של משפחות פלסטיניות‬ ‫בישראל ובגדה המערבית לאחר אבדן בהקשרי לחימה‬ ‫ח'‪ .‬אבו–בקר‪ ,‬עכו‬

‫מטרות‪ :‬גילוי תגובות פסיכוסוציאליות של משפחות פלסטיניות‬ ‫בנוגע לאבדן אישי במהלך האינתיפאדה השנייה בגדה המערבית‬ ‫ובמלחמת לבנון השנייה בישראל‪.‬‬ ‫שיטות‪ :‬נאספו נרטיבים של משתתפים בקבוצות תמיכה בגדה‬ ‫המערבית מתוך טיפולים אינדיוודואליים ומשפחתיים בישראל‪.‬‬ ‫נערכו ניתוחים איכותניים לנרטיבים במטרה לזהות תמות‬ ‫הקשורות לתגובות פסיכוסוציאליות לאבדן במלחמה‪.‬‬ ‫תוצאות‪ :‬התמות אשר נבעו מהנרטיבים של קבוצות תמיכה בגדה‬ ‫המערבית דמו לרוב לאלו אשר נאספו מתוך פגישות טיפול בישראל‪.‬‬ ‫בשני האתרים‪ ,‬אצל משפחות שכולות נראו תגובות פסיכו–חברתיות‬ ‫דומות בכל הקשור לאבדן במלחמה‪ .‬שתי הקבוצות התמודדו עם‬ ‫האבדן באופן קולקטיבי ובהתאם למקובל על פי הרקע האתנו–‬ ‫תרבותי‪ .‬נוסף על כך‪ ,‬אמונות דתיות סיפקו הסברים בשתי הקבוצות‪.‬‬ ‫לגבי משתתפים מהגדה המערבית‪ ,‬מקרי האבדן היו ממושכים‬ ‫ומצטברים‪ ,‬בזמן שבישראל האבדן התרחש לרוב באופן חד־פעמי‪.‬‬ ‫מגבלות‪ :‬שני המחקרים התמקדו אך ורק באבדן אשר התרחש‬ ‫בעקבות מלחמה‪.‬‬ ‫מסקנות‪ :‬סוג הקשר של כל אחת משתי הקבוצות עם מדינת‬ ‫ישראל עיצב את תגובותיה הפוליטיות‪ ,‬הלאומיות והאישיות לגבי‬ ‫האבדן‪ .‬משפחות של "שהידים‪/‬חללים" בגדה המערבית זכו לכבוד‬ ‫סוציו–פוליטי‪ ,‬ואילו בישראל אזרחים ערבים אשר סבלו מאבדן‬ ‫הקשור למלחמה לא זכו לאותו כבוד פוליטי מהחברה היהודית‬ ‫בישראל‪ .‬במקום זאת הם זכו לסימפטיה בתוך קהילותיהם‪ .‬מצבה‬ ‫של קבוצה זו בישראל מורכב מאחר שהמדינה היא גם האויב וגם‬ ‫ספק התמיכה החומרית‪ ,‬הנחמה וההצלה‪.‬‬

‫תרפיה פמיניסטית לאוכלוסייה רב־תרבותית במרכז‬ ‫לייעוץ בנגב‬ ‫ג’‪ .‬צוויקל וא‪ .‬איפרגן‪ ,‬באר שבע‬

‫רקע‪ :‬המרכז לחקר וקידום בריאות האישה באוניברסיטת בן‬ ‫גוריון בנגב הוקם בשנת ‪ .2008‬המרכז מתבסס על מודל טיפול‬ ‫רב תרבותי ופמיניסטי‪ .‬טיפולי הפסיכותרפיה ניתנים על ידי אנשי‬ ‫מקצוע מתחום בריאות הנפש באמצעות מגוון שיטות טיפול‪.‬‬ ‫שיטה‪ :‬נותחו קבצים של ‪ 122‬מטופלות במרכז בשלוש השנים‬ ‫הראשונות להיווסדו‪ .‬הנתונים שנותחו כללו מאפיינים דמוגרפיים‪,‬‬ ‫סיבות הפנייה‪ ,‬הגורם המפנה‪ ,‬סוג ומשך הטיפול‪ .‬שני תיאורי‬ ‫מקרה ממחישים את עקרונות הטיפול רגיש המגדר והתרבות‪.‬‬ ‫תוצאות‪ 62% :‬מהמטופלות דיווחו על טראומה ו־‪ 38%‬דיווחו‬ ‫על בעיה בריאותית בעבר או בהווה‪ .‬הטיפול הנבחר היה‬ ‫בעיקר שילוב של טיפול דינמי ארוך טווח עם טיפול התנהגותי‬ ‫קוגניטיבי (‪.)CBT‬‬ ‫מגבלות‪ :‬המחקר לא הסתמך על כלי הערכה מתוקפים בתחום‬ ‫בריאות הנפש‪.‬‬ ‫מסקנות‪ :‬טראומה מוקדמת מגבירה לעתים קרובות את מצוקתן‬ ‫הנפשית של נשים‪ ,‬והיא משפיעה באופן שלילי על הבריאות‬ ‫הגופנית שלהן‪ .‬שני הנושאים הפכו להיות נושאים מרכזיים‬ ‫בפסיכותרפיה‪.‬‬ ‫בזכות ההכשרה למיומנות בין‪-‬תרבותית במקצועות‬ ‫הטיפוליים‬ ‫י‪ .‬מירסקי‪ ,‬באר שבע‬

‫רקע‪ :‬אנשי מקצוע בתחום בריאות הנפש בישראל מטפלים‬ ‫באנשים בעלי רקע תרבותי מגוון מקבוצות אתניות רבות‪ .‬למרות‬ ‫זאת‪ ,‬הממסד המקצועי לא הגדיר עדיין‪ ,‬ואינו מעודד‪ ,‬אמות מידה‬ ‫רגישות‪-‬תרבות לעבודה עם מטופלים אלה‪.‬‬ ‫שיטה‪ :‬המאמר מציג מודל הכשרה לרגישות‪-‬תרבותית לאנשי‬ ‫מקצוע בתחום בריאות הנפש‪ .‬מוצג גם מחקר שהעריך את‬ ‫ההכשרה‪ ,‬ומבוסס על דיווחים עצמיים של ‪ 51‬בוגרים‪.‬‬ ‫תוצאות‪ :‬המשיבים דיווחו על הבנה טובה יותר של המגוון‬ ‫התרבותי בקרב מטופליהם‪ ,‬על מודעות עצמית תרבותית‬ ‫מוגברת‪ ,‬על אמפתיה ועל כבוד לשונות תרבותית‪.‬‬ ‫מגבלות‪ :‬מדובר בהערכה איכותנית‪ ,‬בהשתתפות מספר מוגבל של‬ ‫בוגרים‪ ,‬והנתונים בה מתייחסים רק להשלכות קצרות הטווח של‬ ‫ההכשרה‪.‬‬ ‫מסקנות‪ :‬מחקר ההערכה מדגים השפעה חיובית של ההכשרה על‬ ‫הפרקטיקה‪ .‬המטרה היא לעודד התייחסות לסוגיות תרבותיות‬ ‫בפרקטיקה ובהכשרה של אנשי בריאות הנפש בישראל‪.‬‬

‫שינוי תרבותי מוצלח‪ :‬הדוגמה של ברית מילה בקרב‬ ‫נשים בשבטים בדואיים ונשים יהודיות שעלו לישראל‬ ‫מאתיופיה‬ ‫ח‪ .‬בלמקר‪ ,‬באר שבע‬

‫ברית מילה של נשים היא תופעה נפוצה אזורים רבים בעולם כולל‬ ‫המזרח התיכון‪ ,‬אפריקה ואוסטרליה‪ .‬אמנם התופעה נפוצה במיוחד‬ ‫באוכוסליות מוסלמיות‪ ,‬אך זה אינו חוק מחייב בדת האסלאם‪.‬‬ ‫בשנות ה–‪ 80‬דווח על נוהג זה בשבטים בדואיים בדרום הארץ‪.‬‬ ‫למחקר הראשון שפורסם ב–‪ 1995‬התראיינו עשרות נשים משישה‬ ‫שבטים שנהגו לערוך ברית מילה לנשים‪ .‬קבוצה מקבילה נבדקה‬ ‫גופנית‪ ,‬ונמצאה צלקת של שריטה בלבד על העורלה של הדגדגן או‬ ‫על השפתיים החיצוניות‪ .‬רוב הנשים דיווחו שהתכוונו להמשיך את‬ ‫המנהג עם בנותיהן‪ .‬מחקר שני שנערך על אותם שבטים שנחקרו‬ ‫במחקר הראשון פורסם ב–‪ .2008‬נוסף לריאיון שערכה אחות‬ ‫דוברת ערבית‪ ,‬התבצעו בדיקות גופניות של אברי המין‪ .‬לא נמצאה‬ ‫אף עדות לברית מילה של נשים בקרב נשים מתחת לגיל ‪.30‬‬ ‫באתיופיה‪ ,‬נוצרים מוסלמים ויהודים ערכו ועורכים ברית מילה לנשים‬ ‫הכוללת כריתה של הדגדגן‪ .‬יהודים שעלו לארץ מאתיופיה מפסיקים‬ ‫מנהג זה מיד עם הגעתם לארץ‪ .‬בבדיקות גופניות של נשים יהודיות‬ ‫שעלו מאתיופיה נמצא כי כשליש מהן עברו כריתת דגדגן‪ ,‬אך לא דווח‬ ‫על אף אחת שמתכוונת להמשיך לבצע מנהג זה לבנותיה ולא דווח‬ ‫בארץ על מקרה של ברית מילה לבנות העדה שנולדות בארץ‪.‬‬ ‫ממצאים אלו מעידים על כך שלחומרת המנהג אין קשר‬ ‫להמשכיותו‪ .‬התוצאות מראות כי יש סיכוי לשינוי חברתי של‬ ‫מנהגים תרבותיים לא בריאים‪ ,‬ומדגישות את החשיבות של‬ ‫הרכיב הקוגניטיבי בשינוי הרגלים תרבותיים כאלו‪.‬‬ ‫דפוסי התקשרות של ערבים ויהודים בישראל – האם‬ ‫הם באמת כל כך שונים?‬ ‫ש‪ .‬לביא‪ ,‬פ‪ .‬עזאיזה ומ‪ .‬מיקולינסר‪ ,‬אריאל‬

‫רקע‪ :‬אוריינטציות התקשרות משקפות ייצוגים פנימיים של‬ ‫העצמי‪ ,‬של אחרים‪ ,‬ושל מערכות יחסים‪ .‬מחקרים קודמים‬ ‫הצביעו על הבדלים בין–תרבותיים באוריינטציות התקשרות‪,‬‬ ‫אך רובם לא כללו מדגמים של ערבים‪ .‬לכן במחקר זה התמקדנו‬ ‫בבדיקת אוריינטציות התקשרות של ערבים בישראל בעזרת מדד‬ ‫מהימן‪ ,‬והשוואתן לאלו של יהודים בישראל‪.‬‬ ‫שיטה‪ :‬משתתפים ישראלים (‪ 292‬ערבים ו–‪ 215‬יהודים) תיארו‬ ‫את דמויות ההתקשרות שלהם ומילאו שאלון התקשרות (‪)ECR‬‬ ‫בערבית ובעברית‪ ,‬בהתאמה‪.‬‬ ‫תוצאות‪ :‬רמות החרדה בהתקשרות שעליהן דיווחו ערבים היו‬ ‫גבוהות מאלו שדווחו על ידי יהודים‪ ,‬אך לא היו הבדלים בין‬ ‫המדגמים ברמות ההימנעות‪ .‬לא היו הבדלים משמעותיים בין‬ ‫המדגמים במגדר של דמות ההתקשרות ובסוג הקשר עמה ‪-‬‬ ‫משתתפים בשני המדגמים תיארו התקשרות עם בני זוג רומנטיים‪,‬‬

‫עם קרובי משפחה ועם חברים‪.‬‬ ‫מגבלות המחקר‪ :‬יש להתייחס לממצאי המחקר בזהירות הראויה‪,‬‬ ‫בשל מגבלות דגימה ומתודולוגיה‪.‬‬ ‫מסקנות‪ :‬ממצאי המחקר הנוכחי עולים בקנה אחד עם ממצאי‬ ‫מחקרים קודמים לגבי הבדלים בין–תרבותיים והבדלים בין‬ ‫ערבים ליהודים בנורמות‪/‬ערכי מערכות יחסים‪ .‬יש מקום לבדוק‬ ‫את ההשלכות הפסיכולוגיות של הבדלים אלו‪.‬‬ ‫התפקיד של מידע חברתי–תרבותי בפגישות ראשונות‬ ‫(‪ )intake sessions‬בבריאות הנפש‬ ‫מ‪ .‬אלגריה‪ ,‬א‪ .‬כץ‪ ,‬ר‪.‬ז‪ .‬אישיקווה‪ ,‬י‪ .‬דיאז–לינהארט‪ ,‬א‪ .‬וולנטין‬ ‫וש‪ .‬ולפטין‪ ,‬בוסטון‪ ,‬ארה"ב‬

‫רקע‪ :‬ארגונים מקצועיים מייעצים למטפלים לספק טיפול מותאם‬ ‫תרבותית (‪ ,)culturally competent care‬אך מעט מאוד ידוע‬ ‫לגבי היישום בפועל של המלצה זו‪ .‬במחקר זה נחקר האופן שבו‬ ‫מטפלים אוספים מידע חברתי–תרבותי‪ ,‬כיצד נעשה בו שימוש‬ ‫וכיצד הוא משפיע על המפגש מטפל–מטופל‪.‬‬ ‫שיטות‪ :‬נאספו נתונים ממרפאות בצפון מזרח ארה"ב‪129 .‬‬ ‫מטופלים ו–‪ 47‬מטפלים השתתפו בשלושה שלבים של המחקר ‪-‬‬ ‫הקלטה באמצעות וידיאו של פגישות ראשונות בטיפול (‪,)intake‬‬ ‫ריאיון איכותני ומידע סוציו–דמוגרפי‪ .‬ניתוח תמתי של הראיונות‬ ‫נעשה באמצעות תוכנת ‪.NVIVO 7‬‬ ‫ממצאים‪ :‬מטפלים עשו שימוש במידע חברתי–תרבותי מכמה‬ ‫סיבות‪ )1( :‬כדי להבין את המופע הקליני של המטופלים‪)2( ,‬‬ ‫על–מנת לבצע אבחנה מיידעת (‪ )3( ,)informed diagnosis‬על–‬ ‫מנת להבחין בין ההשפעה של הפסיכופתולוגיה על ההתנהגות‬ ‫של האדם לבין נסיבות החיים והשפעותיהן‪ )4( ,‬על–מנת ליצור‬ ‫אמפתיה‪ )5( ,‬על–מנת לייחד את המטופל‪ .‬עוד נמצא כי שיפוטים‬ ‫חברתיים משמשים כחרב פיפיות ‪ -‬מצד אחד הם מובילים‬ ‫לסטריאוטיפים‪ ,‬אך מצד שני הם מאפשרים מבט אישי יותר על‬ ‫החולי ועל הניואנסים התרבותיים‪.‬‬ ‫מגבלות‪ :‬הנתונים שבידי החוקרים יכולים להיות מוכללים אך‬ ‫ורק למרפאות ציבוריות בצפון–מזרח ארה"ב‪.‬‬ ‫מסקנות‪ :‬שילוב של מידע חברתי–תרבותי מתגלה כחשוב ביותר‬ ‫וכמאפשר טיפול מותאם תרבותית‪.‬‬ ‫ההשפעה‪ ‬של זהויות חברתיות‪ ‬של מטפלים‪ ‬ושל‬ ‫מקבלי־שירותים‪ ‬על‪ ‬פערים‪ ‬בשירותי‬ ‫הבריאות‪ :‬סקירה‪ ‬של תיאוריה ועובדות‬ ‫א‪ .‬נקש‪ ,‬ת‪ .‬שגיא וי‪ .‬לבב‪ ,‬הרצליה‬

‫פערים בבריאות הנפש הם הבדלים במצב הבריאותי‪ ,‬בסיכונים‬ ‫למחלות ובאיכות השירותים‪ ,‬המפלים לטובה חברי קבוצות‬ ‫חברתיות חזקות‪ .‬אחד הגורמים המוצעים להסבר פערים אלה‬ ‫הוא ההבדל בזהויות החברתיות של מטפלים ומטופלים‪ ,‬המתבטא‬ ‫למשל בעדויות על איכות טיפול ירודה למטופלים השייכים לקבוצה‬

‫כתב עת ישראלי‬ ‫לפסיכיאטריה‬ ‫תקצירים‬ ‫דפוסי שימוש בשירותי בריאות נפש אמבולטוריים‬ ‫בקרב ילידי אתיופיה בישראל‬ ‫ר‪ .‬יונגמן‪ ,‬א פוגצ'וב ונ‪ .‬זילבר‪ ,‬עמק חפר‬

‫רקע‪ :‬היכרותם של עולים מאתיופיה בישראל עם הטיפול‬ ‫הפסיכיאטרי המערבי היא מוגבלת‪ ,‬ובה בעת תרבותם כמעט‬ ‫שאינה מוכרת לאנשי בריאות הנפש בארץ‪.‬‬ ‫מטרה‪ :‬להשוות את דפוסי השימוש בשירותי בריאות הנפש‬ ‫האמבולטוריים של העולים מאתיופיה לאלו של קבוצות‬ ‫אוכלוסייה אחרות‪.‬‬ ‫שיטות‪ :‬עולים מאתיופיה‪ ,‬עולים מברית המועצות לשעבר וילידי‬ ‫ישראל שהשתמשו ב–‪ 64‬המרפאות לבריאות הנפש הממשלתיות‬ ‫ובשירותי השיקום הפסיכיאטרי בכל רחבי הארץ‪ ,‬הושוו ביניהם‬ ‫מבחינת הנתונים הדמוגרפיים והקליניים‪ .‬הנתונים התקבלו‬ ‫ממשרד הבריאות עבור השנים ‪.2003-1997‬‬ ‫תוצאות‪ :‬בקרב העולים מאתיופיה שהיו בטיפול במרפאות‬ ‫לבריאות הנפש‪ ,‬נמצא שיעור גבוה יותר של משתמשים הסובלים‬ ‫מהפרעות פסיכוטיות‪ ,‬שיעור נמוך יותר של מטופלים שהגיעו‬ ‫בהפניה עצמית או בהפניית בני משפחה או חברים‪ ,‬שיעור גבוה‬ ‫יותר של מטופלים שטופלו בתרופות פסיכו טרופיות‪ ,‬ושיעור‬ ‫נמוך יותר של מטופלים שטופלו בפסיכותרפיה אינדיבידואלית‪.‬‬ ‫העולים מאתיופיה השתמשו יותר בשירותי מגורים נתמכים‪,‬‬ ‫ופחות בשירותי חברה ופנאי‪.‬‬ ‫דיון‪ :‬דפוסי השימוש בשני סוגי השירותים נמצאו שונים בקרב‬ ‫העולים מאתיופיה‪ .‬ממצא זה מצביע על הצורך לפתח תכניות‬ ‫רגישות תרבותית הן עבור העולים מאתיופיה והן עבור אנשי‬ ‫בריאות הנפש‪.‬‬ ‫בריאות הנפש וטיפול בבריאות הנפש עבור יהודים‬ ‫בגלות ובפרט בבריטניה‬ ‫ק‪ .‬לובנטל‪ ,‬לונדון‪ ,‬אנגליה‬

‫רקע‪ :‬אצל יהודים בבריטניה נראית שכיחות גבוהה של הפרעות‬ ‫דיכאון למיניהן בקרב גברים‪ ,‬אחוזים נמוכים של התאבדויות‬ ‫והפרעות הקשורות להתמכרות לאלכוהול‪ ,‬ושכיחות גבוהה של‬ ‫הפרעה אובססיבית קומפולסיבית ושל פסיכוזות‪.‬‬ ‫שיטה‪ :‬המאמר משווה משתנים שונים כגון משתני רקע‪,‬‬ ‫אפידמיולוגיה פסיכיאטרית‪ ,‬שימוש בשירותים פסיכיאטריים‬

‫‪israel journal of‬‬

‫‪psychiatry‬‬ ‫ומחסומים לשימוש בהם בקרב יהודים בבריטניה בהשוואה‬ ‫ליהודים במקומות אחרים בעולם‪.‬‬ ‫תוצאות‪ :‬בבריטניה יש שכיחות גבוהה של דיכאון בקרב יהודים‪,‬‬ ‫נשים וגברים כאחד‪ .‬לעומת זאת‪ ,‬השכיחות של הפרעות חרדה‪,‬‬ ‫התמכרות לאלכוהול והתאבדויות היא מהנמוכות בעולם‪ .‬לא נמצא‬ ‫דפוס ברור ואחיד בכל הנוגע ל–‪ ,OCD‬לפסיכוזות ולהפרעות‬ ‫נפשיות אחרות‪ .‬מכשולים או חסמים לחיפוש שירותי טיפול ושיקום‬ ‫פסיכיאטריים קשורים בדרך כלל לסטיגמה ולחוסר אמון במערכת‪.‬‬ ‫מגבלות‪ :‬חסרים נתונים מספקים על הפרעות נפשיות‪ ,‬על צריכת‬ ‫שירותים פסיכיאטריים ועל השפעה של דת‪.‬‬ ‫מסקנות‪ :‬גורמי סיכון להפרעות נפשיות שונות כוללים גם‬ ‫אנטישמיות‪ ,‬שממנה סובלים יהודים בבריטניה ובעולם‪ .‬גורמים‬ ‫מגנים קשורים במסגרת משפחתית תומכת ויציבה‪ ,‬בתמיכה‬ ‫חברתית ובדת‪.‬‬ ‫טראומה והשלכותיה בקרב בדואים המשרתים בכוחות‬ ‫הביטחון ובני משפחותיהם‬ ‫י‪ .‬כספי וא‪ .‬קליין‪ ,‬חיפה‬

‫רקע‪ :‬מעט ידוע על ההשפעות של טראומה ושל הפרעה פוסט–‬ ‫טראומטית (‪ )PTSD‬על בני מיעוטים מתרבויות לא מערביות‬ ‫המשרתים בצבא ובכוחות הביטחון‪ ,‬ועל התגובה של בנות זוגן‬ ‫ובני משפחה אחרים‪.‬‬ ‫שיטה‪ :‬הושלמו ראיונות עם ‪ 317‬גברים בדואים המשרתים בכוחות‬ ‫הביטחון ומתגוררים בגליל‪ ,‬עם ‪ 129‬מבנות זוגן ועם ‪ 67‬אימהות‪.‬‬ ‫תוצאות‪ :‬תועדו רמות גבוהות של חשיפה לטראומה ושכיחות‬ ‫של ‪ PTSD‬בקרב הגברים‪ .‬נמצא שגילויי תוקפנות של הבעלים‬ ‫‪1‬תיווכו באופן מלא את הקשר החיובי החזק שנמצא בין‬ ‫ה–‪ PTSD‬של הבעלים לסימפטומים פוסט–טראומטיים ודיכאוניים‬ ‫ולמצוקה גופנית של נשותיהם‪ .‬לעומת זאת‪ ,‬המצוקה הרגשית‬ ‫והגופנית הגבוהה יותר של האימהות לא הייתה קשורה כלל‬ ‫באבחנה של בניהן‪ ,‬אלא באופן חלקי בגילויי התוקפנות שלהם‪.‬‬ ‫מגבלות‪ :‬שיטת הדגימה‪ ,‬מערך המחקר הרטרוספקטיבי‪ ,‬והיעדר‬ ‫נתונים על עיתוי התעוררות הסימפטומים‪.‬‬ ‫מסקנות‪ :‬חסמים תרבותיים משמעותיים מחייבים גישה אקטיבית‬ ‫לטיפול באנשי הצבא וכוחות הביטחון המשתייכים לתרבויות לא–‬ ‫מערביות‪ .‬על הגישה האקטיבית לכלול‪ )1( :‬זיהוי וטיפול ראשוני‬ ‫בסימפטומים פוסט–טראומטיים לפני השחרור‪ )2( ,‬חינוך גורמים‬ ‫בקהילה‪ )3( ,‬הכשרת רופאי משפחה בקהילה לזיהוי ‪PTSD‬‬ ‫והבעיות הנלוות להפרעה זו בקרב אנשי כוחות הביטחון ובני‬ ‫משפחותיהם‪.‬‬

israel journal of

psychiatry

Ma n a gi n g s u b o p t i m a l res p o ns e to antid ep res s ant therapy

Seroquel XR ‫הוספת‬

50% -‫הוכחה כמשפרת בכ‬

‫את סיכויי ההגעה‬ ‫לרמיסייה בדיכאון‬

Culture and Psychiatry

Vol. 49 - Number 3 2012

ISSN: 0333-7308

151 Psychiatric services and Ethiopians in Israel

2

‫בהשוואה לטיפול בנוגד דיכאון בלבד‬

Rafael Youngmann et al.

159 Volume 49, Number 3, 2012 Israel Journal of Psychiatry and Related Sciences

-on

d d A

‫חדש‬ Seroquel XR is indicated for add-on treatment of major depressive episodes in patients with major depressive disorder (MDD) who have had suboptimal response to antidepressant monotherapy.1 The recommended daily dose is 150mg, however if clinically justified the dose may be increase to 300mg.

Seroquel XR is also indicated for schizophrenia and bipolar.1

08-13-SER-12-IL-030

References: 1. Seroquel XR MoH Approved Prescribing Information 2. Bauer et al. Journal of Affective Disorders 2010; 127:19–30

09-7406528 :‫ טלפון‬,43656 ‫ רעננה‬4070 .‫ד‬.‫ת‬ Israel.infoisrael@astrazeneca.com 09-7406529 :‫פקס‬ Seroquel XR® is a registered trademark of AstraZeneca group of companies.

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Mental health of Jews in the U.K. Kate Miriam Loewenthal

167 Community study of Bedouin servicemen Yael Caspi and Ehud Klein

178 Female circumcision RH Belmaker

184 Attachment patterns of Arabs and Jews Shiri Lavy et al.

194 Sociocultural information at intake Margarita Alegria et al.

202 Social identities and mental health disparities Ora Nakash et al.

MDD (Add-on)

150mg

‫עכשיו מאושרת בישראל‬ 1 ‫כתוספת לטיפול בדיכאון‬ ‫חדש‬ ‫זמינה כטיפול לדיכאון בביטוח‬ ‫המשלים של חלק מקופות החולים‬

211 Palestinian families and War in Israel Khawla Abu-Baker

219 A women's counselling service in the Negev Julie Cwikel and Andrea Ifergane

227 Cultural competence training Julia Mirsky