The Shortage of Arab Professionals in Mental Health Services – Causes and Solutions
Irit Elroy, Hadar Samuel, Tamar Medina-Artom
Mental health reform in Israel went into effect in 2015. The reform created a legal right to care and stipulates a basket of treatments and services incumbent upon the health plans to provide to all insurees within a reasonable period and a reasonable distance. The goals include the integration of mental and physical health and the establishment of a continuum of care, the improvement of quality of care, reduction of the stigma involved in the provision and receipt of mental health care, and the expansion of service availability and accessibility.
The reform was planned on the assumption that it would expand the number of patients by making services more available and by reducing the number of persons in need who are reluctant to turn to mental health care.
In a 2012 study examining the prevalence of need of mental health services, 24% of the Arab respondents stated that they had experienced mental distress in the preceding year, and had found it difficult to cope on their own. Of the Jewish respondents, the percentage was 17%. Of those reporting mental distress, 14% of the Arab vs. 36% of the Jewish respondents had turned to seek care (Elroy et al., 2017).
As part of the efforts of the Ministry of Health (MoH) to narrow gaps between Israel’s various populations, a Director-General’s Circular of February 2011 instructed the health plans to provide culturally- and linguistically-competent health services. Research indicates that ethnic-cultural matching between therapists and patients has many advantages in providing culturally-competent care to minority populations, and that the main method of providing it is to develop an ethnically and culturally varied cadre of professional therapists. However, over the years, minority groups have been under-represented in the various mental health professions in some countries, including Israel. This is particularly true for Israel’s Arab population, even though as regards other medical disciplines and practitioners – such as physicians, nurses, and pharmacists – their representation is commensurate with their share of the population. Thus, for example, a 2013 study funded by the Israel National Institute for Health Policy and Health Services Research, and examining the preparedness of the health plans for the mental health reform, found at an early stage that the health plans had already reported difficulty in recruiting Arab mental health professionals. This report is consistent with the findings of a study examining structural and geographic gaps in state mental health services for children. The findings also indicated a shortage of Arab mental health professionals in state mental health services.
The topic of shortage of Arab mental health professionals has been on the agenda of several bodies (such as MoH, the Council for Higher Education [CHE], and the Authority for Economic Development in the Arab, Circassian and Druze sectors). Yet, to date, no comprehensive study has been conducted on the topic in Israel. There is a lack of data on the obstacles to training and integrating Arab professionals in mental healthcare or on the contributing factors. This study will help both understand the causes for the shortage and contribute to the development of suitable strategies to address the problem.
The goal of the study is to identify the obstacles to recruiting Arab students into the various training tracks for mental health professions – psychology, psychiatry and clinical social work – and the factors encouraging their integration into these tracks. The study examined the unique training track of each of the mental health professions, beginning with the decision to choose a higher education discipline and ending with the commencement of a career. Other study goals were to learn of existing solutions to cope with the obstacles and to suggest additional modes of action to increase the supply of Arab professionals in these disciplines.
The study consisted of interviews with four groups of informants: head-office personnel from ministries and health plans (15), senior academics (7), key stakeholders in the Arab community (4), and Arab professionals in mental healthcare (27) – psychiatrists, psychologists and mental health social workers.
For each group, a semi-structured interview protocol was developed. Each was asked about the reasons for the shortage, the place of cultural adaptation in mental health, and possible solutions to reduce the shortage. Furthermore, every questionnaire had specific questions for the group to which it was administered. Thus, for example, professionals were asked about their experiences along the career route, whereas academics were asked about the difficulties facing Arab society with respect to higher education. The interviews were recorded and transcribed, and the content was analyzed to identify the main themes. The content analysis for each profession considered five stages of training and career development: admission to higher learning, university studies, choice of mental health as one’s field of studies, advanced studies and specialization, and joining the job market. We identified the similarities and differences between the training tracks and different stages in the tracks. Accordingly we recognized the points of potential intervention, and drew recommendations about these points from the findings.
Attitudes toward the Need for Linguistic and Cultural Adaptation of Mental Healthcare
In the interviews, we investigated the respondents’ general conceptions of culturally competent mental health care. The interviewees ascribed importance to culturally- and linguistically-competent care; their concerns were broader than just language, relating to additional dimensions such as values, religion and norms. The respondents noted that in order to provide an appropriate response to all facets of Arab society, both Jewish and Arab therapists should receive training in culturally sensitive therapy.
Obstacles in Integrating Arab Students in Training Tracks for Mental Health Professions
Obstacles Facing Young Arabs on the Way to Acquiring a Profession
Like the descriptions in the literature on minority groups, the study found that Israel’s Arab population must overcome a range of structural, financial and cultural obstacles on the road to acquiring a profession. Some of the obstacles described in the interviews apply to all young Arabs in Israel attempting to pursue higher education, acquire a profession and integrate into the job market. These obstacles are structural – such as deficient learning infrastructure in the education system (resulting in low-level preparedness for academic studies, including difficulty in English and Hebrew), and inadequate study skills throughout the training track; financial – the difficulties arising from the necessity to work while studying and the lack of financial backing or family support, especially among groups with few resources; and cultural – relating to the lack of cultural adaptation of the curricula and practicum.
Obstacles Specific to a Mental Health Career
The respondents also described obstacles specific to mental health training and employment tracks: structural – the high threshold requirements throughout the studies and training in psychology, medicine and social work, and the limited exposure to vocational guidance regarding the choice of a therapeutic profession in mental health; financial – the low recompense in comparison with other professions and the fact that the training tracks are long and demanding; cultural – the stigmatic perceptions of mental health, the lack of awareness of the therapeutic professions in the field, and the lack of academic and professional role models in their environment .
Another important finding relates to gender. The interviews showed that the above-mentioned obstacles assume greater force in the case of Arab women. Living in a traditional society, they are tasked with obligations that traditionally are their exclusive domain, such as taking care of children and the extended family, and living in close proximity to the husband’s parents. Since mental health professions have long training periods compared with other possible occupations, conflict arises between traditional obligations and training requirements.
Also mentioned in the interviews was the question of Israel’s socio-political context and its implications for the mental healthcare environment. Mental health professionals described dilemmas that crop up during treatment if a patient voices distress related to the Arab-Jewish conflict, particularly in times of crisis or war. These complexities raise concerns and undermine the therapists’ confidence in their ability to cope with issues of security, politics and national identity.
Factors Supporting the Integration of Arabs into Mental Health Training Tracks and Employment
Only a small number of factors supporting the training of Arab mental health therapists were cited. One main factor related to broader social processes, which have brought about a positive change in the way that Arab society views mental health. Moreover, there has been increasing exposure to mental health in Arab localities due to the establishment of specific mental health clinics and the growing presence of educational psychologists in schools. This has contributed to raising awareness of mental health professions and reducing the stigma connected to receiving treatment.
Some mental health professionals described their knowledge of the shortage of Arab professionals in mental health as a factor contributing to their choice of a career in this area. They perceived it as an opportunity to integrate into the mental health field whether because of considerations of job security or a sense of mission and social commitment. Also mentioned were the support and encouragement lent by lecturers in academia and professionals on the ground to Arab students, which are perceived as unique and significant in the process.
Concerning the stage of entering into working life and finding employment, MOH and Health Plan senior staffs noted that they are “desperately searching” for Arab professionals in mental health disciplines. On the other hand, the professionals’ themselves did not mention during the interviews any supporting factor regarding entering working life and finding employment. In fact, some of the interviews reveal a perception among Arab professionals that these professions do not have a guaranteed employment horizon. Thus, there appears to be a mismatch between the way that Arab professionals perceive the job market and the way that its perceived by senior MOH and HP staff.
Current Solutions for Integrating Arabs into Mental Health Training Tracks
The findings indicate that over the years, academic institutions, health funds and MOH mental health facilities have developed local and sporadic solutions to attract and encourage Arab candidates to the mental health discipline. These solutions are aimed at addressing the above-mentioned obstacles. For example, in the interviews, some mental health professionals described activities that they had personally encountered to ease the admissions process and adjustment to higher education for Arab students, such as: affirmative action in admissions, the establishment of a shell of support during pre-academic preparatory studies, health-plan funded initiatives to attract mental health residents, and the establishment of specific centers for the Arab population with more relaxed hiring criteria. In their interviews, the head-office personnel noted that currently, initial activity has begun to promote the matter on the national level. Measures include according Arab candidates priority in line for clinical specialization; exposure to the field of mental health in Arab high schools; and MoH funding to train Arab social workers in psychotherapy. Nevertheless, most of the professionals interviewed were unaware of these system-wide solutions.
Suggested Solutions for Integrating Arabs into Mental Health Training Tracks
The interviewees were asked to suggest their own solutions to address these obstacles. The suggestions offered by the different informant groups may be divided into two main categories:
One category is aimed at expanding the pool of Arab students accepted to mental health training by addressing the structural and financial obstacles deterring potential candidates from higher studies, particularly in the field of mental health. Thus, for example, in the case of Arab students applying to psychology, affirmative action was suggested at junctures with high prerequisites for professions in great demand. Specific affirmative action measures included (1) conditional acceptance to an undergraduate degree for students not meeting the prerequisites and (2) the accordance of less weight to first-year marks and to scores on entry exams for a graduate degree to enable more Arab students to apply to clinical psychology. Solutions relating to adjustment difficulties focused on linguistically- and culturally-competent learning: for example, having Arab faculty members accompany the students at university, or improving the accessibility of curricula by rendering them in Arabic. It was also suggested that Jewish academics receive special training in cultural sensitivity.
The other category is aimed at encouraging candidates (including those meeting the prerequisites for the mental health field), to choose this field over other career routes. Solutions in this category include both addressing the cultural obstacles and changing perceptions of mental health in Arab society, such as: raising awareness of mental health as a career possibility, and the stigmatization of patients and care providers. Some of the ideas mentioned to raise awareness included greater exposure to the field in the education system, the media and the community; developing community mental health services; and expanding the approved positions for educational psychologists in schools. Another suggestion was to expose medical and social-work students to the field of mental health in order to improve the chances that they would choose to specialize in it.
Other suggestions related to the financial burden of long training tracks: offering scholarships for the study of psychology, and financial incentives both to encourage the choice of a mental health career throughout the lengthy training and to remain to work in the public sector once trained. To address the uncertainty of employment, suggestions were made to increase the number of formally approved positions for mental health residents and specialists in the various professions, and to open a specific, direct study track for psychology in Arab society, following on directly from undergraduate studies and continuing through the completion of specialization.
Discussion and Conclusions
The findings are consistent with the picture emerging in the international research, whereby minorities encounter difficulty in integrating into mental health disciplines because of poor academic background, that is a hindrance for integrating into employment in general; socio-economic background that demands rapid integration into remunerative employment; and cultural background that includes stigmatic perceptions toward mental health in general and therapists in particular.
In this study, we concentrated on identifying the junctures of career tracks that potentially lend themselves to intervention for purposes of increasing the proportion of Arab professionals in mental health. We found that while the issue is on the agenda of several organizations, many of the solutions described by the mental health professionals are localized rather than a part of a comprehensive strategy.
It is clear from the findings that the obstacles deterring potential candidates from the field of mental health are not limited to a particular stage in the training track, or to a specific area of studies. Moreover, many of the obstacles cited in the interviews derive from inequality in a range of systems in Israel, not directly related to the health system, which, however is influenced by it. They should therefore be addressed at the multi-system level with the cooperation of the various ministries involved (health, education, finance and labor / social services) and the various agencies related to training and employment processes (CHE, institutes of education and training, hospitals, health plans etc.). To be effective, it is important that the solutions be carried out systematically by the establishment and be supported by clear policy and dedicated budgets. Since the process involves a large number of organizations, some of which already operate various programs to promote Arab society, it may be important to designate a lead organization to oversee the topic.
The suggested solutions revealed that to increase the mental health workforce, two courses of action are open: raising the number of training candidates by increasing the rate of participants in higher education and improving the pre-university academic infrastructures, on the one hand, and “channeling” potential candidates from other professions to mental health by providing incentives for choosing it. In the short term, steps should be taken to retrain manpower from related professions (social work or educational psychology), and to provide incentives for working in the field. In the long term, steps should be taken to raise awareness of the mental health field and create culturally-competent training tracks. These steps should be carried out with the cooperation and coordination of the various stakeholders. Both these courses of action should be accompanied by cross-cutting activities to promote mental health awareness in Arab society and reduce the stigma connected to the provision and receipt of therapy. In deciding on, and executing, these decisions, Israel’s unique cultural characteristics must be considered, and care must be taken to ensure that these processes be carried out with cultural sensitivity.
The study was funded by a research grant from the Israel National Institute for Health Policy and Health Services Research