Following the Form of Mental Health Reform - Why and How to Study Monumental Changes

by Jonah Goldberg

Israel underwent a large-scale reform of mental health care in 2015, transferring responsibility for mental health care from the state to the health plans and thereby making mental health part of the benefits package that everyone in Israel is entitled to. Beginning in 2008, when the reform was first being planned, the Myers-JDC-Brookdale Institute has been instrumental in its evaluation.

“It’s doing something in the very basic foundation of the way that we treat people,” says Hadar Samuel, a research scholar in the Society and Health Policy team at MJB. And the life-changing potential of the reform means MJB could not be anywhere else.  “With any change, it’s important to follow up, and see if the good things we want to be happening are, and the bad things we don’t want to be happening aren’t, and if they are, to be able to say, ‘we should fix this.’” 

MJB is studying the implementation of the reform from new angles, including changes in professional practice and complex obstacles to the reform’s goals. Only by evaluating this legislation through its layered consequences and the decisions of the people whom it affects can MJB enable the public and private parties involved to improve their work and enact future policies using the most evidence and experience possible.

Accessibility of Treatment

One major challenge Hadar and her team have studied is citizens’ access to mental health services. A notable achievement of the reform is the doubling of the number of mental health clinics in Israel.  Yet this improvement has shed light on just how severe the need for mental health treatment is, as all of the clinics still suffer from long wait times.

Hadar notes that this lag between the need and availability of service is not only problematic for patients today; it also shifts clinics’ priorities in a way that blocks them from solving any other issue. “What you get is a system that--even though they’ve doubled the clinics out there--is still struggling with giving the most basic treatment. They’re not thinking about innovation and making new kinds of treatment. They’re still struggling with just finding enough psychologists and psychiatrists to get the most basic treatment available.” The health plans need to ensure they can get every patient through the door before they can work on what is behind it.

Lack of accessibility varies regionally and demographically. The issue is more pronounced in Israel’s periphery, as, despite the country’s small size, more and better care is concentrated in Israel’s center. Moreover, the Arab and Haredi populations have greater difficulties receiving proper care. Strong communication and dialogue are vital in mental health treatment, meaning these patients need therapists and treatment approaches representative of their backgrounds. This, in turn, requires having more minority professionals in the workplace. Filling these jobs taps into another series of challenges.

Accessibility of Work

One of MJB’s biggest research focuses is the shortage of Arab mental health professionals. While Arabs comprise 21% of the Israeli population, they make up less than 2% of its psychology and psychiatry workforce. The institute has been the first to delineate the causes of this issue by speaking to existing Arab workers. Hadar explains, “They’ve gone through this… there aren’t many of them, but they are the best resource to ask.”

The Arab interviewees shed light on several points where their career pipeline leaks. Socioeconomic factors play the largest role; becoming a psychologist or psychiatrist takes 10 years of schooling and training, and it pays less than most other medical professions. This creates two opposing problems. First, many Arabs are not able to support themselves to start a career in this field. Second, those who can have little reason to choose mental health; families encourage medical students to pursue more lucrative and prestigious careers, such as surgery and gynaecology. 

With this study, MJB has proposed solutions to increase the size of the Arab mental health workforce. One avenue would be to support Arab students in their education, by having Arab faculty mentor students and by employing affirmative action and scholarships for psychology students. Another path would be to raise awareness of mental health as a viable career option. Most Arab interviewees did not realize how many openings for Arab mental health professionals need to be filled. Greater exposure to the mental health field in education and media might help Arab students to choose this field over others; it may also decrease the stigma around receiving and practicing mental health care.

Negative ideas of mental health treatment remain a monumental barrier to overcome in providing care to everyone who needs it. Yet there are also stigmas within psychology practice that affect proper treatment.

Changing Models of Care

Hadar is currently analyzing the data from an exhaustive survey of professional work practices. MJB interviewed psychologists, psychiatrists, and social workers in 2011, just before the reform passed into law, and again in 2018, asking everything from how many hours were spent on paperwork and bureaucracy relative to seeing patients, to what they saw as the benefits and challenges of the reform. 

The first vital change MJB saw was that workers in the public sector report diagnosing far more dystemia (a mild but chronic depression) and anxiety disorder cases. As the professionals had hoped, many people who previously got treatment only in the private sector or not at all have now been able to receive help from the public sector.

The tools of diagnosis have also changed in the past decade. The percentage of practitioners who use projection tests has decreased from 37% to 16%; unfortunately, the percentage who use house calls has also decreased, from 24% to 4%. Hadar attributes the latter change to a cost barrier that the reform has not helped. On the other hand, evidence-based practice, which “psychologists really hated,” is becoming increasingly common. Professionals were now more likely to say evidence-based practice is important and a consideration when planning treatment for a patient.

The Ultimate Goal

Israel’s mental health reform “goes a long way to put mental health and physical health on the same playing field.” Hadar believes that further reforms and changes in practices need to continue to increase integration between these two fields. “We want family physicians to also think about patients’ mental health, and we want psychologists and psychiatrists to also think about physical health, because we know these things come together. We know that those with severe mental health problems have more physical health problems, and tend to die younger.

“These two systems used to be very set apart--different finances, different management systems, even entitlement was different. You had the basic health package for physical health, and for mental health, you had whatever the ministry could give. It even depended on time of year; if you came late, the ministry might say, ‘we’re out of money, come next year.’ You still need to wait now, but no one is going to say, ‘you’re not eligible,’ or ‘we’re out of money.’”

The past few years have shown the beginnings of better integration. Family physicians are more likely to ask their patients about emotional distress, and more of those who report feeling distress have received treatment. Through our exhaustive study of the reform’s impact on accessibility to mental health care and careers as well as mental health practices, MJB is helping to further this goal, ensuring that mental health care is considered a priority and made available to everyone.