Back into the light

Thanks to a revolutionary law passed in 2000, Israelis coping with mental illnesses are being helped back into society.

hopeful 311 (photo credit: Kansas City Star/MCT)
hopeful 311
(photo credit: Kansas City Star/MCT)
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.
IT WAS 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.
“Imagine 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 audience.
“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 the basket.
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 Treasury.
The Health Ministry’s new director-general, Dr.
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.