At various points in our lives, most of us will experience feelings of sadness, depression, anger, an inability to concentrate, mood changes and feelings of withdrawal. At what point do these feelings and behaviors become symptomatic of mental illness? And if that happens, how can these problems be treated? When are the warning signs of mental illness in children and teens?
In the corona-era Israel of 2021, how best can English-speaking Israelis treat mental health issues?
“I was taught that we don’t actually define mental illness as a disease,” says Dr. Shmuel Harris, a psychiatrist and former head of psychiatric services at Hadassah-University Medical Center on Jerusalem’s Mount Scopus, and current director of Machon Dvir, a behavioral health clinic in Jerusalem.
“Disease connotes a specific etiology, that we know what causes it and its clinical presentation, such as streptococcal pneumonia. We know that streptococci infect the lung and cause inflammation, and exactly what pneumonia is. We can see it and test it under the microscope. We can’t do that for any mental illness, and hence we call it ‘disorders.’ “Disorders connote two fundamental features: either subjective distress, or objective or functional impairment. That’s really how we define mental illness.”
Harris explains that the way to determine if someone is mentally ill is by the amount of distress being caused.
“If it is causing you subjective distress or functional impairment, that would be the way that we see it.” Nevertheless, he cautions that being occasionally troubled is not necessarily an indicator of mental illness.
“We all get distressed at times. Does that mean that now we have a mental disorder? Having a day or two of that doesn’t automatically mean you have a mental disorder. We’re all allowed to have ups and downs and to be anxious.”
Harris explains there are definitions clinicians use to determine mental illness. “Take the most simple one. Depression requires at least a two-week period of a poor mood of anhedonia – the inability to feel pleasure – of disinterest, feeling down with the associated symptoms.”
How can someone ascertain if children are having mental health issues? Harris says it would be indicated by subjective distress or functional impairment.
“Look at their academic or scholastic functioning, if they can get to school, if they are able to do well at school. Socially, do they have friends? How well are they managing? In the area of social media, [look at] the extent of use and how dependent they are. Are self-esteem issues impairing their functioning in social and academic domains? And how are they feeling as well?”
Ultimately, he suggests, the best way is for parents to speak directly to their children and ask them how they are doing, to get an idea as to how they are functioning at home, in social situations and at school.
If someone, or a member of someone’s family, is having feelings of depression or experiencing other forms of mental illness, where can they turn for help?
DR. HAIM BELMAKER is a Modi’in-based psychiatrist who worked in Israel’s public health system for 45 years before opening a private practice three years ago, and served as president of the Israel Psychiatric Association from 2015 to 2018. He says the first step one should take to treat a mental health disorder is to book an appointment for mental health services with the local health funds, even if their schedule is full and the appointment might not take place for several months.
Belmaker says that in the period between when the session is booked and the actual date of the appointment – which might be several weeks away – one should reserve an appointment with a private therapist for a one-time consultation.
“Look privately and get some advice on a one-time basis on a direction,” he says. “That is usually not too expensive. It will give you some perspective, and it will make you more intelligent when you go back to see a kupat holim psychiatrist.”
Belmaker notes that a private psychiatrist will not take offense if you state openly that you are coming for a one-time visit to get advice on how to proceed in the kupah. He also suggests it is important to define the nature of the mental health issue and the type of treatment required in order to best treat the ailment.
“Always bring up with both the kupah and the private doctor: ‘Are there other professionals who could work with me if you define the problem? Do you think this a problem that I could work on with a coach, or a social worker or marital counselor? How can you help me make this affordable?’”
Belmaker suggests clients should be open about the financial cost and type of treatment they need.
“The idea the public has – that they want to see a professor of psychiatry every week for all aspects of the problem, including parts that could be treated by other professionals who might be less expensive – hurts the public.”
Belmaker concedes that English speakers, particularly those not fluent in Hebrew, can have difficulties communicating with health fund therapists who are not fluent English speakers.
“I have dealt with patients who complained to me that they asked for an English-speaking therapist, and I gather this is not always available,” he recounts. “There is a long waiting list for a therapist, and that is another constraint that the system might not be able to fulfill.”
Belmaker says there is a lack of qualified psychiatrists in Israel.
“There is a tremendous shortage. I think that few Israeli medical students go into psychiatry because we are a practical country, and psychiatry seems like an introspective and theoretical profession.”
He points out that many of the country’s leading psychiatrists are immigrants from the United States and the Russian aliyah of the 1990s, a large number of whom will be reaching retirement age in the next few years.
NAOMI RAZ, a Jerusalem-based psychotherapist in private practice, agrees that English-speakers might encounter difficulties when seeking help for mental health issues via the kupat holim system.
“They will have a fairly difficult time if they can’t find an English speaker. It’s closed down to them if there aren’t English-speaking therapists available.” She adds that finding private English-speaking therapists can be difficult because therapists who are fluent are almost always fully booked.
Hinda and Avi Schryber are veteran social workers and co-founders of Orlenefesh, a Jerusalem-based organization that provides social work, counseling and advice to adults with serious mental health problems, as well as rehabilitation programs and sheltered housing projects since 2001. They say that many services and avenues of assistance are available to those who are mentally ill.
“Anyone who has a mental health diagnosis is entitled to apply to the National Insurance Institute for disability benefits,” Hinda explains.
Applicants can go to the NII website, fill in an application and submit it with a letter from their psychiatrist. Once their application is reviewed, they will be invited to appear before a medical committee that will decide on the percentage of disability benefits to which they are entitled. Benefits can range from housing in hostels and communal living facilities to subsidies for independent living, where they reside in their own apartments with the help of a social worker or counselor. Disability benefits from the state’s sal shikum (rehabilitation basket) for the mentally ill can provide assistance with studies, dental care, rent subsidies and more.
The Schrybers say that 30% of their clientele is English-speaking, and that many in the Anglo community are not aware of the availability of these services.
Hinda Schryber voiced criticism of some private mental health practitioners: “Many practitioners themselves do not know about the service and are providing their clients with a partial service, because they are not providing what the sal shikum can provide, and are not informing their clients that they can get the sal shikum. It is a huge disservice. Until I stop working, I will continue to battle this.”
She adds that even those who are seeing private therapists are entitled to the benefits of the sal shikum.
IT IS difficult to ascertain the exact number of private practice English-speaking psychologists, therapists and psychiatrists in Israel. GethelpIsrael.com, which advertises itself as a one-stop-shop for mental health needs, lists 12 English-speaking psychiatrists, 70 psychologists, 198 therapists, and 13 life coaches on its site. Undoubtedly, there are other English-speaking mental health professionals practicing in Israel who have not joined the GetHelpIsrael list.
There is also a Facebook group titled Anglo Mental Health Professionals in Israel with 136 members. Two notable private organizations that provide mental health assistance for English speakers are Machon Dvir and Kav LaNoar.
Machon Dvir was founded in 2016 by the aforementioned Dr. Harris, together with Dr. Tzachi Fried, who at the time was a clinical psychologist in private practice. Harris explains that they decided to create the organization after treating many English-speaking seminary and yeshiva students in Israel on one-year programs who had been sent to the emergency room after experiencing episodes of losing control or expressing threats of self-harm.
“The educational framework would be freaked out,” Harris says. He adds that seminaries and yeshivot feel ill-equipped to handle these cases, and send these students to hospital emergency rooms. Often, the schools send the students home because they have no real framework for managing these types of cases.
“From a clinical perspective, I thought it was completely unnecessary. There was no reason for these people to be sent home. They needed a bit more help, but they were not really high-risk.”
Harris points out that in many cases, non-suicidal self-injury is a call for help and a way of expressing a difficult situation or a way to manage psychological pain.
“I realized that they didn’t need to be sent home, but the school was not prepared to assume the responsibility. The idea for Machon Dvir was to set up a higher level of care – not inpatient, but as an integrated service.”
Most seminary and yeshiva students on one-year programs, says Harris, do not have access to the services provided by kupot holim, and they need an English-speaking service that can treat them in Israel. While Machon Dvir primarily works with such students, it has expanded its services and provides services for all English-speaking young adults ages 18-25.
The organization has clinics in Jerusalem and Beit Shemesh, and specializes in Dialectical Behavior Therapy (DBT) in English. Developed by Dr. Marsha Linehan in the late 1970s and early 1980s, DBT helps people manage strong and overwhelming emotions. It is an offshoot of Cognitive Behavior Therapy (CBT), which is often used for anxiety, depression and other conditions.
DBT combines problem-solving with validation and acceptance of the patient by the therapist, and provides therapeutic skills in four areas: Mindfulness improves the ability to remain present, nonjudgmental and accepting in the current moment. Distress tolerance increases a person’s ability to experience conflict and difficult emotions. Emotional regulation helps manage behaviors by learning how to respond rather than react to intense emotions. And interpersonal effectiveness provides techniques to allow a person to communicate with others directly and assertively, thereby strengthening relationships.
Harris explains that while DBT was initially developed for borderline personality disorder, it can be used to treat other issues.
“If we step away from diagnoses and talk about clinical presentations,” says Harris, “DBT is a great skill to have for anyone who has significant difficulties regulating emotions – if they are sensitive or they get overwhelmed very easily, or experience emotions intensely and find it difficult to calm themselves down.”
Harris notes that DBT has encountered some resistance in Israel.
“There is a cultural issue within the Israeli mental health community,” he says. “It goes back before DBT to CBT. There is a very strong psychodynamic culture in Israel. When the Jews were leaving Europe, the Jews were running psychotherapy – people like Sigmund Freud and Melanie Klein. Those therapists who came to Israel laid the groundwork for a strong psychoanalytic, psychodynamic culture which has held up the embracement of cognitive behavior therapy.”
Harris says the 2015 reforms in Israel’s mental health system, which transferred responsibility for hospital and ambulatory mental health services to the health funds, hastened the adoption of CBT and DBT among the kupot because they are unable to provide long-term therapy and are utilizing more evidence-based and short-term therapy.
Harris also notes that there is less stigma attached to treatment for mental health issues now than there once was, and more encouragement to seek treatment when necessary, particularly among seminary and yeshiva students. He adds that the pandemic might have contributed to this trend since therapy is increasingly being offered via Zoom and is much more accessible.
ANOTHER TREATMENT option positioned between the kupat holim and private clinics is the Kav L’Noar Lamerchav mental health clinic in Ramat Beit Shemesh, which provides no-cost outpatient psychotherapy services for the English-speaking community of Beit Shemesh and surrounding communities.
Dr. Zev Ganz, director of the Ramat Beit Shemesh clinic, which opened in October 2020, explains, “Until now, the primary and most direct way of getting therapy has been to go to a private therapist, which is very expensive. On the low end, it would be between NIS 300 and NIS 450 [per session], and at the high end up to NIS 700. Not everyone can afford that, and it’s not an option for many people. There are organizations like Hakshiva and Emuna, which offer specific types of therapy that cost about NIS 150 per session.”
By contrast, he says, the services offered at the Kav L’Noar Lamerchav clinic are fully covered by all the kupot except Maccabi, yet they offer privacy and a setting that is conducive for successful therapy. He adds that the therapists in the clinic are experienced clinicians and are familiar with the needs of the English-speaking population.
“Olim have the same issues that everyone else does,” says Ganz. “The needs and sensitivities of olim – what they go through – are sometimes not so easily accessible to someone who doesn’t have that life experience.”
All of the clinic’s therapists are olim or children of olim and have experience working with the English-speaking immigrant population.
“If you come to our clinic, you know you are getting someone who is not only a well-trained therapist but someone sensitive to what you have gone through in the aliyah process, and an English speaker,” he notes.
“The Kav L’Noar Lamerchav clinic is a generalist practice, and its therapists work with children, adolescents, couples, families and adults, treating a range of issues, including depression, anxiety, family problems, couples’ issues and difficulties with children. We take on a lot,” says Ganz. The kupot set the limit on therapy at one year.
Despite the difficulties in obtaining adequate mental health services for English-speakers in Israel and the stigmas that still exist, Shmuel Harris thinks things are looking up.
“There is reason to be positive and hopeful that things are changing in Israel, and there are services that exist. I think that especially the English-speaking community is probably in a much better position than... the wider Israeli community and definitely other sub-communities. The English-speaking community has a very large number of well-trained therapists.
“I think that there are more services that need to exist, and there is more that needs to be done, but there are a lot of reasons to be positive.”