It’s the framework for mental health care that needs treatment

How long does it take to become an independent, registered psychologist in Israel? That depends on several factors. The first is how quickly you progress in your studies, which include a BA, a difficult test (“Mitam”) to get into an MA and the course of the MA itself. More crucially, the length of your road to independent work depends on how fast you can begin your residency period – and that's where things get tricky. A psychologist's residency is four years at a part-time pace. In some fields starting a residency is easier: for instance, educational psychology, managed by the Education Ministry (while most others are under the Health Ministry), actually has a shortage of residents. In other fields, most notably clinical psychology, one encounters a different picture. “I got my MA in adult clinical psychology from Tel Aviv University a few years ago,” recalls Or Ghez, now a resident of Beit Shemesh. “I handed in my MA thesis in October 2014. Then there were a few months of waiting to get a license. Only in January can you start applying for a residency in private-owned clinics, and only in March do you get onto the Health Ministry's waiting list for [public] residencies.” This waiting list consists of about 300 names; naturally it shifts back and forth over time. “Every couple of months the ministry posts a list of available scholarships,” explains Dana (not her real name), an MA graduate who studied child clinical psychology and finished her degree duties in 2016. Scholarships are residency opportunities sponsored by the state. Dana has been on the list and waiting her turn for about a year. “When I first got in I was No. 305 on the list; now I'm at 218. There's currently a threeyear wait for a residency. When a scholarship is announced, you can apply for it and the top five numbers on the list who applied are called in for an interview. Personally, even though I'm from central Israel, I apply to Beersheba, Haifa and other places farther from the center. It's been a year and I've never even been called in for an interview.” Ghez waited for two years until she found a residency. During that time she tried to apply to private clinics, too. “They would tell me they're fully booked until 2018 and I should try them again in early 2017 – this was in January 2016. It's not only that there aren't enough places to apply to, it's also about how often they take in new people.” At one point she was called in for an interview in Jerusalem. Living in Holon, her interviewers told her they are very impressed but are looking for someone who lives much closer, knowing that many people realize the trip is too far only after they've started work, and quit shortly after. A month or two later she saw another opening, this time in Beit Shemesh. Since that clinic is under the same management as the one she interviewed for in Jerusalem, she already knew the people in charge, and emailed them directly, making the point that this location was significantly closer to home. She finally got the job. ACCORDING TO the head psychologist's office in the Health Ministry, there are currently about 2,500 psychologists doing their residency in Israel. About half of those are clinical psychologists, of whom 41% (524) are in the public healthcare system. The other half consists of educational, rehabilitation, medical, developmental and occupational psychologists, with varying degrees of public-to-private proportions. Currently waiting for state-funded residency are 443 clinical psychologists. Some 134 of them have completed part of their residency and are waiting to continue, but most haven't started at all yet, and another 115 are in other specialties. Waiting time for is officially stated as one and a half years, though that number varies according to which source you ask. Even when a residency is attained, the problems don't end there. Residencies pay little and require a lot, says Noa Ramer, a developmental psychology resident and member of the Movement for Public Psychology in Israel. “People wait for over a year, some two or three years. Then during the residency the problem is that the salary is very low… it's hard to make a living. I myself work at three additional jobs.” Ramer says she makes NIS 3,200 a month for her part-time position as a resident, which is not only hard to live on but “is not appropriate for the amount of training [psychologists have] or their professional responsibility. Some patients come in with very difficult life situations, some are suicidal or having a psychotic episode… There's a gap between the meager salary and the responsibility and commitment the system requires.” Nor is the job truly so “part-time” – residents are paid for a half-time position but work many extra hours because of the strain on the system. As a resident, she sees patients waiting to get treatment for months on end. “A child with autism or retardation could wait months for their evaluation,” she adds, giving as an example a case of an autistic child with behavior problems whose parents had to wait with the child at home for four months just to get their official diagnosis, which is a necessary step in getting rights from the National Insurance Institute, treatments, an appropriate kindergarten and more. “The root of the problem is that Israel has no national action plan mapping the population's needs for public psychology services,” explains Shai Itamar, a clinical psychology resident and member of the Board of Clinical Psychology Residents. “There's no map you can turn to and ask, how many [psychologists] do we need in this or that sector? How many of them should be in the public service?” According to Itamar, about 210 people graduate with an MA in clinical psychology every year in Israel. A similar number finish their residency every year, he explains, but even though the numbers seem to add up, it's hardly a one-out-one-in situation, because of the long waiting list and because residents who finish their role are not always replaced immediately (or at all). “When I entered the list three years ago I was last in line at No. 150; the list doubled in length since then. I waited on the list for about a year, and once I realized it was just not realistic for me, I started searching for a residency in the private sector.” Itamar says he found a place within a couple of months, but that is due to the fact he was living in Beersheba, away from central Israel, and happened to be at the right place in the right time. Statistics for private residencies are harder to collect, so it's difficult to say whether the average waiting time is short or long, “but either way,” says Itamar, working in the private sector “means making a compromise. When you're in the public sector you are entitled to certain working conditions: vacation days, a [steady] monthly wage. You make just over minimum wage in your early 30s, often just when people want to start a family and stand on their own, but when you turn to the private market, even those NIS 3,200 are a dream. I work on an hourly basis, and that means my salary can fluctuate: in the summer I have fewer patients and I earn less. I happen to work for a place that takes care of my social rights, pension, etc, but we in the Board hold surveys about this and we know that pay violations are more common in the private sector. THERE'S NO doubt that becoming a psychologist in Israel is difficult and that the process is problematic, to say the least. At the same time it could be argued that the Health Ministry's job is not to take care of psychologists, but to take care of the public in need of them. Is it possible that the country just doesn't need that many psychologists? “We need to separate the public's needs from the psychologists' needs,” says Ruth Bernstein-Peretz, an educational psychology resident and the residents' representative in the Israeli Psychological Association. “Our organization's role is to consider both, and make sure the public sector will provide a comprehensive solution to the entire population: both in the center and in the periphery, both for adults and for children and the elderly, and from all angles: clinical, developmental, occupational and so on. “There are not enough psychologists in the public sector right now, but on the other hand, I'm not sure anyone knows how many there should be… In terms of residents, the bulk of them are clinical psychologists. I'm not saying there are necessarily too many, I'm just saying we can't tell if we really need any more, and presenting as a solid fact that we need more [clinical residents] presents reality inaccurately,” says Bernstein-Peretz. Clinical psychology gains the most attention in this matter, she explains, but it is hardly alone in the matter, and other specialties suffer severely, too. It's an important fight, she says, “and I don't want to take an inch from what [clinical residents] deserve, but the real problem is really not theirs but the public's,” and surrounds the more marginalized parts of society. For instance, says Bernstein-Peretz, apart from rehabilitation hospitals, there is hardly anyone providing medical and rehabilitation psychology services. There are also too few developmental psychologists because not enough people want to study the profession. “Even in educational psychology, where it appears as if the situation within the system itself is better, you still don't have enough psychologists. For most educational psychologists, that's not even what they studied. “And if someone goes through rehabilitation – physical, cognitive, mental, whichever – they don't get any public help finding employment, which results in a serious financial loss for the country. Instead of paying allowances and emptying the National Insurance, we should be using occupational psychologists to help them return to some level of occupational functioning.” Not to mention the great lack of services for special populations such as the Arab and Ethiopian sectors and in the geographical and socio-economic periphery. Looking at the bigger picture is not only looking beyond clinical psychology but beyond psychology entirely, at other needs of the system. “Are there enough psychologists in public service? Of course not,” says Gabriel Peretz, head psychologist in the Health Ministry. “But psychologists are not the only ones in charge of mental health in the country. There are also psychiatrists, social workers and more. “As head psychologist, I want the majority of professionals providing therapy to be psychologists; they are trained for this to begin with and they are best at it. But there are also social workers who have studied psychotherapy. They know how to treat and they do it well. I think a mental health clinic should have several different professions in it, because a wide, multi-profession outlook is beneficial to therapy.” Furthermore, says Peretz, the system's decisions take a wider view of things. “It's not as if the entire public sector has a surplus and only psychologists are missing budgets. We are currently doing extensive examinations of the subject to find out what the public's needs are, how many psychologists are necessary.” Peretz also points out a problem in academia in this regard. “There's no state-level plan that academia goes by, and it trains students according to its own considerations.” One source from the higher education system had said universities in general are in fact beginning to limit the number of students they take in; another source pointed out that while their own classes have indeed grown smaller in recent years, isolated and uncoordinated responses of the sort are not the right direction, as any sort of 'vacuum' in the system will soon be filled by other schools. One solution that both sources suggested was to show more flexibility in the nature of treatment itself, to better fit the system's lack of resources – for instance to put more emphasis on short-term treatments (from various approaches), or to have some simpler client issues handled by other professions with shorter training periods. An alternative model worth noting for the academia/system chasm can be found in the Baruch Ivcher School of Psychology in the Interdisciplinary Center Herzliya. The school runs its own private clinic, where the general public can receive treatment from residents – recent graduates of the school. Dr. Ety Berant, head of the clinic, explains that they don't automatically hire all of the school's graduates, that there still is a serious screening process, but overall, the majority of their graduates do find a place there. Treatment in her clinic is naturally cheaper than private sessions, and while it's not necessarily cheaper than public treatment, it is stable, whereas public services can become more expensive over time. (Clients can also seek treatment from students doing their practicum, which is more subsidized.) Berant points out two advantages of this particular solution. First, client information is kept private – they don't have to share their difficulties with their general physician and nothing goes into their healthcare file. Second, the direct connection to the school means that their treatment is “guided by research. We check ourselves, [clients] fill in questionnaires, you can check their mental status when they first start treatment and when they're done and see which parameters change… that makes treatment more focused and successful.” The public psychological services' current status is very problematic, says Berant. “At the end of the day, there is real shortage in the field; it's not as if schools are training unnecessary psychologists. Our work in the clinic has shown me just how much distress exists about this. We see disadvantaged populations where there's not enough [public] manpower to treat them.” That missing manpower does include clinical psychologists, she adds, as they can care for other populations like teenagers or people suffering from chronic schizophrenia. “I don't think there are too many [clinical psychologists], the demand is very high. Our clinic is not small, and yet all our residents have their hands full.” A similar clinic exists at the Bar-Ilan University and perhaps more schools will open clinics in the future, which certainly could help shorten graduates' waiting periods. What may stand in the way is financial resources; the IDC clinic is sponsored mainly by the school, a private college, which also provides rooms, electricity and other services, a significant addition to client payments. EVEN IF more academia-owned clinics do open, the fact that the public's needs are not really mapped makes it hard to predict just how many more residency spots will solve the public's side of the problem. According to the Health Ministry, the average waiting period for beginning psychotherapy is somewhere between two and six months, in some places even longer, and before you can start your sessions, the average waiting time for meeting with a psychiatrist is around two to three months. This last point is crucial: one of the changes brought about by the mental health reform, which was put into action two years ago, is that in order to be eligible for public psychological treatment you need to have a psychiatric diagnosis, such as depression, manic-depressive disorder, ADHD and so on. The problem is that not all people who need mental help fit that description, explains Yarden (last name withheld), a child clinical psychology resident and member of Benafshenu, an organization of psychology and social work students, residents and specialists. “A child whose parents got divorced, or a teenager who has been raped, or a person who was fired and can't find a job – those [don't necessarily warrant diagnosis]. They are life conditions that can cause a crisis and need to be treated.” In such cases, says Yarden, some doctors agree to find a “nearby'”diagnosis, as so not to prevent their patients from getting psychotherapy, but that's not an easy solution. “If you get a diagnosis, it goes into your medical file. If you apply for work in a government office or enlist in the army, anyone can see it.” She says the reform, in theory, had a great purpose – to improve the level of mental health care available to the public – but the execution is another story. The new system adds a lot of bureaucracy each step of the way, and it so far failed to significantly increase the number of service providers. “It's not that people didn't have to wait in line before the reform, but it was easier at least to prioritize urgent cases over others. That's harder to do now,” says Yarden. The reason prioritization is harder to do is that the reform moved the responsibility over mental health care from the Ministry to Israel's HMOs (Clalit, Maccabi, etc.), which have their own procedures and priorities. “The Health Ministry allocated huge amounts of money for this reform,” explains Yarden. “NIS 2 billion went to the HMOs. Where is this money? It was used for covering debts. Only 50% of it was actually used for mental health care. We are aware that two years is not a long time when it comes to reforms, but this one has been 'cooking' for 20 years, and even when the general terms were decided it still had two or three years until it came into effect. That's enough time to recruit more people, open new service points, discuss the issue of diagnoses.” Lack of sufficient regulations is another problem with the reform, adds Itamar. “Up until two years ago the state was responsible for providing services to anyone who wanted them and needed them, including psychological services.” He sees the shift to HMOs as a highly unsuccessful one. “No standards were defined for the quality of the psychological service, the number of sessions, [which profession] provides those sessions… And you still need to wait a long time for your treatment. Places that had low access still do.” When it comes to mental help, he says, time is of the essence. “In Beersheba or in northern Israel, you could wait six months, a year, sometimes even more… with children, for instance, that's a catastrophe. Waiting a whole year when your child suffers from depression or anxiety, that could affect them their entire lives. A problem you might have been able to solve easily for a four-year-old is much more complex at 16.”

It’s the framework for mental health care that needs treatment

The reason prioritization is harder to do is that the reform moved the responsibility over mental health care from the Ministry to Israel’s HMOs, which have their own procedures and priorities.

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