When today’s most-veteran Israeli psychiatrists got their first positions, many
people with serious mental disorders would spend long periods – and some the
rest of their days – locked in psychiatric wards. The patients were expected to
follow orders, and might have been tied up; they weren’t asked what they wanted
to do with their days, and certainly not with their lives.
But with the
improvement in techniques, including medications, and the greater stress on
individualism, civil rights and personal welfare, such a scenario is impossible
today. Most patients are regarded as having the potential for recovery – some
with symptoms, some without – and the ideal place for them is at home or in
community-based hostels. The number of inpatients has been halved in the past
few decades, while the number undergoing rehabilitation has doubled. Such people
are no longer called “patients” or “the mentally ill” but mitmodedim (“copers”
in Hebrew), and even given the neutral title of “clients” or “customers,” as if
they were shopping in a department store.
All agree that the surge of
rehabilitation services for those recovering from psychiatric illness – which
run the gamut from depression and bipolar disorder to addictions and
schizophrenia – is a highly welcome change. And while 17 years ago, the Health
Ministry established a special department for the rehabilitation of people
coping with psychiatric illness, the most important boost came from a bill
developed and initiated by a single MK – Tamar Gozansky of the leftwing Hadash
Party – and the experts she consulted over a period of three or four years. It
was passed unanimously on July 11, 2000, and the budget for its implementation
was allocated the following winter.
SINCE THEN, organizations around the
country arose to provide rehabilitation – social, vocational, emotional,
educational and leisure time, as well as housing – for them, and many former
patients have pushed ahead to a normal or near-normal life, even marrying,
having children and joining a profession.
The organizations are paid by
the ministry from a set budget (and not what the Treasury agrees to give each
year, or what is left over after paying for the treatment of the general
population’s physical illnesses.
“Ordinary MKs can have more influence
than ministers,” said Deputy Health Minister Ya’acov Litzman, greeting the
ministry’s one-day Jerusalem conference marking the 10th anniversary of the
passage of Gozansky’s bill. When a video of the historic vote was shown at the
beginning of the conference to the more than 1,000 participants in Jerusalem’s
International Convention Center, they broke into warm applause.
described by Israeli and foreign experts as “one of the most important pieces of
social legislation in Israel, and one of the most enlightened laws of its kind
in the world.” In fact, Dr. Michael Hogan, commissioner of the New York State
Office of Mental Health – who arrived specially for the convention – said
Gozansky’s law had produced “greater accomplishments” since 2000 than New York
State and even the whole US had achieved during the same period.
that you have only begun,” said Hogan, who disclosed that part of his motivation
for going into the field was the fact that he has a brother who suffers from
schizophrenia. “You cannot imagine what you will achieve in the next 10 years.
Dream high, and you will achieve much more,” he assured the
“Recovery” no longer refers only to the symptoms of serious
mental illness going away, but also to former psychiatric patients regaining a
normal life and achievements despite having some symptoms. “We who work in
hospitals and clinics don’t see those who don’t come back because of the
progress they have made. We see only those people who are still sick,” the
American psychiatrist said. “While not all will be cured, don’t give up on
anyone. Mental health recovery is a journey. This understanding requires a new
approach to care; it is not just treating symptoms.”
Until the 2000 law
was implemented, people with psychiatric illnesses were entitled only to medical
treatment, but had no rights to social, occupational, housing and other
services, and there was no set budget. Those people who were recognized as
having a 40 percent or greater disability due to mental illness were entitled to
Among those who gave the law strong backing was then-health
minister and Shas MK Nissim Dahan (described by many as among the best-ever
health ministers, even though he left the government, his party left the
coalition and he abandoned politics).
The community assistance programs
were initiated and supervised by Yehiel Shereshevsky, a psychologist dubbed “Mr.
Rehabilitation,” who joined the ministry’s rehabilitation department from its
beginnings after working as chief psychologist and then managing mental health
rehabilitation efforts in the community after the law went into effect. Known by
his youngish face, longish gray hair and beard, crocheted kippa and informal
dress, Shereshevsky plans to move on next year.
WHILE THE law has
built-in guarantees, Litzman said it is still not so protected that the Treasury
could not take bites from it. But he announced that all NIS 150 million his
ministry is allocated in 2011 for development will go to the upgrading,
expansion and renovation of existing psychiatric hospitals and other facilities
and the construction of some new ones, as the scandalous and degrading
conditions in some, including the Abarbanel Mental Health Center, made headlines
in recent years. The basket of rehabilitation services might even be expanded,
the deputy minister added.
Earlier this year, Litzman announced his
about-face on the issue of whether to transfer responsibility for psychiatric
services from his ministry to the health funds. He strongly opposed it as
then-chairman of the Knesset Finance Committee. But seeing the decline in
services as nothing happened due to ongoing disputes among the ministry
professionals, he reluctantly decided to support this reform. The Knesset is due
to start debating the issue soon. Advocates argue that when the health insurers
take responsibility for mental health services, those who need them will lose
the stigma because they will be regarded as all other medical treatments – and
budgets will not be dependent on what the Health Ministry manages to drag out of
The Health Ministry’s new director-general,
Ronni Gamzu, said he was moved by what he saw and heard at the
convention. “It motivates me to help the system, and it needs a lot. I am
devoted to this challenge. Rehabilitation of recovering psychiatric patients is
the next big thing in health systems, not only in Israel but around the world.
There is finally a lot of willingness and understanding.”
Dr. Gadi Lubin,
the new head of the Health Ministry’s psychiatric division, said at the
conference that the Gozansky law “has been inscribed in golden, luminous letters
in the book of Israeli legislation,” and that he hoped the proposed reforms
would also be successful.
A just-released University of Haifa study on
the effects of the Gozansky law at the conclusion of its first decade found that
the efficacy of the “basket of rehabilitation services” is high. “People with
mental limitations who use these services have a higher quality of life and
fewer symptoms,” wrote the researchers, who will publish their findings in the
next issue of the Israel Journal of Psychiatry.
Prof. David Roeh and
colleagues at the community mental health department in the university’s welfare
sciences faculty compared 595 people with serious psychiatric disorders who
received these services and 596 with similar medical and demographic
characteristics who had not yet done so. Those who took advantage of the basket
reported greater participation in study, leisure and sports activities, better
social and community connections, improved family relationships, higher income
and better employment, as well as more satisfaction with their housing. Despite
the importance of rehabilitation services, in fact, fewer than 20% of those
entitled to them actually use them. He hopes the results of the study will
encourage all of those entitled to them to apply for what they deserve, and that
it will help improve the quality of their lives.
Shereshevky, who was
introduced by Prof. Uri Aviram – chairman of the National Center for the
Rehabilitation of Former Psychiatric Patients in the Community – said that
before the law was passed, “we almost didn’t recognize the patients’ needs and
desires. Today, there is more joint decisionmaking.
And there are 150
recovering patients who work in rehabilitation themselves.”
In the late
1970s and 1980s, he continued, “there were many psychiatric patients who no
longer had to be inpatients because their medications alleviated their
disorders, but there were no community frameworks for them. I can’t forget the
sight of 15 people dressed in khaki uniforms in a ward room; when they moved to
another ward, they had no personal belongings to take with them. They never
voiced any complaints.” Today, there are only 3,400 inpatients in psychiatric
hospitals; it used to be twice that number. Nearly 16,000 are undergoing
rehabilitation through services supervised by the ministry, and 30,000 have gone
through the system.
Another foreign guest speaker, Prof. Graham
Thornicroft – head of the health and population research department of the
Institute of Psychiatry at King’s College, London – said the stigma of mental
illness is one of the most formidable problems in rehabilitation. When patients
are ashamed and their neighbors regard them as having an infectious disease,
they will never be integrated. He noted that New Zealand has programs that have
effectively reduced the stigma by increasing direct contacts between the general
public and patients and encouraging patients to disclose their past. “Social
contact triggers population-level change in stigma.”
And the walls of
stigma collapsed, if only for a few hours, when ”patients” sang and played
instruments beautifully on stage and video interviews presented others at home
coping with daily routines.