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10.
COMPARISONS BETWEEN UK AND ISRAELI MENTAL HEALTH SERVICES.
In meeting with a range of
professionals and visiting many services for people with mental
health problems I was able to identify similarities and differences
between systems in the UK and Israel. In some ways Israel is a long
way behind the UK, for example in hospitalising psychiatric patients
for long periods in large hospitals which are often many miles away
from patients' homes. However there are elements which we have lost
in our move to community-based care, and which we might return to.
For example:
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People in the community with
enduring problems (eg schizophrenia) are routinely offered a place at
a sheltered workshop, vocational training centre or similar. This
gives people structure to their day, a role in life, a modest extra
income and social contact, as well as allowing professionals to
unobtrusively monitor mental health on a daily basis. Israeli staff
were amazed that in the UK we do not see the provision of meaningful
daily activity as central to a person's mental well being.
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There is much more readiness
to see personality disorder (particularly borderline personality
disorder, BPD) as a perfectly valid diagnosis for management by the
mental health services. The diagnosis of BPD does not mean an
individual is discharged as "not mentally ill". It is
accepted that, while a 'cure' may not be possible, effective
management of the problem certainly is. Clients with BPD often
receive psychosocial interventions alongside clients with psychotic
disorders. Not because the two conditions are fundamentally similar,
but because both groups benefit from firm boundaries, reliably stable
relationships, feedback on their effect on others, a socially
motivating environment and social skills training (whether formal or informal.)
11. I will write an article
summarising the differences between the two systems, and suggesting
what we might learn from Israel, for the professional press in the
UK. This would also be an opportunity to describe the Churchill
Fellowship and encourage other NHS staff to make applications in
future years.
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12.
CRITICAL INCIDENT RESPONSE.
One area where Israel is
sadly but understandably ahead of the UK is in the response to
disasters and major incidents. This is evident in the range of
services available and standing by to intervene after an incident,
and in the range of techniques in common use to deal with Post-Traumatic
Stress Disorder (PTSD). These include:
13. I was able to gather
detailed manuals and syllabi for EMDR, TIR and TOT, though I was
already familiar with EMDR. I Will make these available to the PTSO
team in my workplace, and will discuss their wider use with senior managers.
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4. PALESTINIAN SERVICES.
As well as visiting many
mental health facilities run by the Israeli Health Ministry and other
Israeli non-governmental bodies, l was able to visit one facility in
the Palestinian Territories. This is the rehabilitation project run
by the East Jerusalem YMCA at Beit Sahour near Bethlehem, six miles
south of Jerusalem. The project works with Palestinian people who are
physically disabled and psychologically distressed. This population
does not receive a service from Israeli organisations (because the
West Bank, although occupied by Israel, is not claimed by Israel and
no health or social support infrastructure is provided.) Initially
clients were referred during the Intifada, the Palestinian uprising
against Israeli occupation. Traditionally, disability has been seen
as a stigma in Arab society and something to be hidden. Disabilities
sustained during the Intifada, on the other hand, are seen almost as
something to be proud of - certainly not a mark of shame. This has
made it easier for people to come forward and seek rehabilitation
from disability, and there is a knock-on effect which means that
people whose disability arises from other sources are first easier to
come forward themselves.
 I
5.The YMCA rehabilitation project provides residential treatment,
both for physical rehabilitation and work with PTSD. They also
provide community support via six community teams in the major Arab
population centres in the West Bank. They are a major provider of
clinical supervision and counselling training in the Palestinian
community, where such concepts are relatively new. They have also
provided critical incident support and long term follow-up, notably
after the Hebron massacre when 29 worshippers in a mosque were killed
by a lone Israeli gunman.
16. I was very impressed by
the high level of facilities and services provided without any
government support. The YMCA project receives support neither from
Israel (who do not take responsibility for services to Arabs in the
Territories) nor from the Palestinian Authority (whose priorities are
in political and security matters.) I will write an article for
publication about the project, either for the professional press or
possibly for a news publication.
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17.
CASE MANAGEMENT.
During my visit I was invited
to attend a conference at the Joint Distribution Committee (JDC) in
Jerusalem. The JDC is a very high profile institution which channels
voluntary aid (approximately $800 million per year) from the USA to
Israel. The conference was a bi-national meeting between
representatives from universities, ministries and practitioners in
Israel and academic institutions in North Carolina, USA. The aim was
to develop bi-national research proposals to make a bid for funding.
18.The conference was a
valuable experience of work at that level, and also gave me some new
information. One concept I was familiar with was that of the
"learning organisation", another which was new to me was
that of formal case management. This is an approach developed in the
USA to work with clients who have complex needs and who are served by
a number of different agencies - for example children with severe
mental health problems who might be receiving specialist health,
education and social services.
19.The idea is that one
person, the case manager, should very actively co-ordinate the
activity of all agencies and that this should be done at a senior
level. I thought at first that something like this was already in
place in the UK (under the Care Programme Approach for mental
illness, for example). However it was clear that case management as
explained to me was much more developed and taken much more seriously
in parts of the USA and Israel. For example, case managers receive
specific and detailed training on the practice of case management and
the responsibility and constraints of all agencies (not just their
own.) They are supported by agreements at senior management (board
level) in each agency, and delegated considerable powers to convene
meetings, require the attendance of others and commission services.
Some case managers work for free-standing case management
organisations, rather than one of the provider agencies.
20. I collected a large
amount of written material on case management and have a number of
references to follow up. If there is interest from HERCH I will offer
to make a presentation to senior managers (and those of other
agencies) describing the approach in more detail.
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21.
VOLUNTARY SECTOR
Several of my meetings with
representatives of voluntary agencies representing users of mental
health services and their carers. One well-established organisation
is Enosh ("Humanity"), which is modelled on the UK National
Schizophrenia Fellowship. Enosh runs a network of day centres and
sheltered accommodation across Israel, rather as MIND does in the UK
but without MIND's political and campaigning activity. The high
profile of the Churchill Fellowship meant that I met the
founder/President of Enosh and was treated as some kind of visiting dignitary!
22. I also met
representatives of two smaller organisations Hitmutadrut
("Coping") and Benafshenu ("In our soul".)
Hitmutadrut runs a network of self-help groups for people recovering
from mental illness. Benafshenu is trying to develop a campaigning
and awareness-raising role on behalf of users of mental health
services. One activity is in a locality of Jerusalem where complex
mental health cases are discussed by a multi-agency consultation team
to try and find a way forward. The client who is the subject of the
case and a representative from Benafshenu both attend and take an
active part in the whole discussion.
23. A further Benafshenu
project is called Dialogue, and involves offering training to users
and ex-users of the mental health services so that they can make
presentations to professionals. The idea is that users could be
usefully involved in the training and professional development of
staff. In particular, Benafshenu are keen to provide an experience
for staff (and the user volunteers) which reverses the usual
provider-consumer roles and makes staff think hard about their
attitude to clients.
24. The Benafshenu
representative I spoke to said they had no links with similar
organisations in the UK, and felt as yet somewhat under-developed in
their role. I offered to put them in touch with MIND to see whether
there was any support they could give to this nascent user
organisation. Equally, I felt we had something to learn from the
Dialogue training, and will ask my employers and MIND locally whether
they would be interested in learning more about this from Benafshenu.
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