1 The Psychotherapeutic Professions in Israel G. Shefler 1,2, O. Tishby 1, and H. Wiseman Hebrew University Jerusalem, Israel 2 - Herzog Ezrat-Nashim Mental Health Center, Jerusalem Israel 3 - University of Haifa, Israel I. Current Situation of the Psychotherapeutic Professions 1. Identity of the psychotherapeutic professions. Psychotherapy is practiced in Israel traditionally by three main helping professions: clinical psychologists, clinical social workers and psychiatrists. In addition there are numerous practitioners from various professions and occupations such as: Educational counselors, medical, educational and rehabilitation psychologists, expressive therapists (art, dance, bibliotherapy, etc.), GPs, nurses, youth counselors who try to practice and sometimes to pursue psychotherapy studies and training in various frameworks. Clinical Psychologists (a) about 4000 professionals practicing mainly psychodynamic psychotherapy in various theoretical approaches. (b) They hold M.A. or Ph. D. degrees in clinical psychology, and they undergo 4 years of part-time, internship (20-hours weekly) concentrated on psychotherapy and psychodiagnostics. The final registration examination consists of a written case presentation and a psychodiagnostic evaluation which are submitted before the oral exam. (c) There is an official mandatory psychologist registry run by the Ministry of Health, which functions as the licensing authority for psychologists in Israel. Several professional organizations are: Israel Psychological Association (formerly the official registry of psychologists), Israel Association of Psychotherapists, various psychoanalytic societies and
2 2 institutions and some more specifically oriented psychotherapeutic associations such as Hypnosis, Family Therapy, CBT, Group therapies, etc. (d) The psychologists' registry is run according to the Law of Psychologists (1976), and serves as the authority for professional licensing. All other organizations, institutes and societies are voluntary, and are conducted by Rules of conduct and Codes of Ethics. (e) Clinical psychologists gain much respect and prestige from the public, but on the other hand the definitions and the differences between the professionals are not recognized clearly. Clinical Social Workers (B.S.W. or M.S.W.) There are about 12,000 social workers in Israel. (a) Social workers in Israel practice psychotherapy, even though they practice in addition a wide range of other methods of intervention such as rehabilitation, drug counseling, interventions with victims of sexual and physical abuse, case management, etc. The main therapeutic orientation is psychodynamic, and in addition family therapy is practiced mainly by social workers. (b) In social work - training and licensing for psychotherapy have not been officially defined. The typical training for the psychotherapist consists of training in a private institute with individual/group supervision, and post-academic professional studies such as psychotherapy or psychoanalysis courses. Recently the Union of Social Workers has defined a "subspecialty in mental health" with specific requirements (M.S.W., course work and training). (c) There is a very strong union of Social workers, which gains its strength from the huge number of SW that are members (over 10,000 members). They practice various SW techniques and not only psychotherapy. (d). The same as with clinical psychologists.
3 3 (e) As mentioned above, the public does not differentiate between the various professions of psychotherapists, yet in a public clinic sometimes patients will react to the fact they are referred to a social worker therapist and will claim they are in good socioeconomic conditions and they do not understand this decision. Psychiatrists (a) There are about 750 active professionals. They work mainly in mental health centers both inpatient and outpatient units. (b) Their internship is 5 years long, in psychiatric in and outpatient units as well as neurology wards. They are trained and supervised in psychotherapy as well. Their final examination includes various subjects in psychiatry and neurology, the presentation of two psychotherapy cases, from two different theoretical frameworks and different durations. Most of the psychiatrists in Israel prefer to practice medication treatment and only a minority keeps on practicing and training in psychotherapy, and only very few pursue further psychoanalytic training. (c) The professional license is issued by the Ministry of Health according to the Doctors Order. All MDs in Israel are members of the Israel Medical Association. Psychiatrists are members also in the various professional associations and institutes mentioned before. (d) Psychiatrists in Israel are commonly in leading positions as directors of hospitals clinics and wards. They often appear in courts and give evaluations. (e) The public usually associates psychiatrists with medication treatments. In the early eighties, and for the next fifteen years, attempts were made to implement "the law of psychotherapy" which was intended to increase dramatically the range of licensed professionals who are allowed to practice psychotherapy. As of yet, this law has not been passed due to two major obstacles: (a) lack of a definition of psychotherapy agreed by
4 4 professionals and judicial experts; and (b) political tensions among many groups with conflicting interests in the implementation of such a law. The current status is that each of the three main professions is regulated by a separate law, and anyone who claims to practice any of these professions without the appropriate credentials is considered an impostor. On the other hand, anyone who wants to practice treatments, such as "spiritual treatment" or "healing", "coaching" or even "therapy" can do so. In order to deal with this absurd situation, there was an attempt to establish the law of psychotherapy 20 years ago, which proved unsuccessful. The main barrier to passing such a law was an inability to agree on a professional and legal definition of psychotherapy. Political strains among different professions did not help in resolving this issue. The process that was involved in developing the law prompted many professionals to seek some psychotherapeutic training in order to be recognized as professionals. These were: nurses, GP's, occupational therapists, educational psychologists, educational counselors, and pedagogues. In order to fulfill this need- numerous private training programs were established. Psychotherapy in various forms and methods is common in Israel. The main theoretical framework is still psychodynamic though there has been recently some change in this respect in the direction of cognitive-behavioral therapy. As for prestige and status; Clinical psychology is coveted by many young people. The criteria for admission to graduate programs are tremendously high (GPA and an exam similar to the GRE). These criteria do not reflect the needs of the profession but rather the need for selection. The general public does not differentiate between all the professions listed above. Psychiatrists are usually associated with drugs and insanity, social workers- with social incapacities and problems and the psychologists are associated with mental problems and emotional difficulties.
5 5 2. Relations among psychotherapeutic professions. The current situation is that the leading professionals in psychotherapy are clinical psychologists (CP). This is the professional group that practically and officially invests the most effort in psychotherapy training. Nevertheless, they are engaged in numerous conflicts as follows: a. Conflicts between CP and psychiatrists (who are traditionally and practically the directors of clinical settings in Israel). Their main complaints are against the isolation of psychotherapy from the realm of the patient and the systems, the amount of supervision hours required by CP. b. Conflict between CP and other psychologists regarding one of the sections in the Psychologists' Law that allows only CP to practice psychotherapy. This section is about to be changed as a results of pressure from psychologists who are not clinical. c. As mentioned before most of the veteran practitioners practice psychodynamic therapy. Currently there are new conflicts between them and younger therapists who have been trained in CBT, systemic therapy and other approaches (e.g. somatic experiencing). d. Conflict between the non-professionals or semi- professionals and the professionals. 3. Relation of the professions to the health care and/or social services systems. Sadly clinical psychologists in Israel find themselves nowadays in three major professional and political conflicts, and in each we are quite segregated. a. The reform in mental health services: In 1996 the national health insurance law was established. It included all fields but mental health, geriatrics and chronic nursing. All medical services but these three will be supplied by the health insurance agencies. The reform was meant to be implemented within one or two years, but this has not yet happened. The main problem regarding the practice of psychotherapy is the plan to limit drastically the
6 6 number of sessions that patients can receive in public agencies, which will of course affect the work and activities of clinical psychologists. b. The section in the law of psychologists which allows only clinical psychologists to practice psychotherapy is currently under change, due to pressures of rehabilitation, medical and educational psychologists. c. A conflict that seems to be between psychodynamic versus CBT approaches is undergoing under the flag of Evidence-Based Treatments (EBT), claiming that CBT has solid research evidence while psychodynamic approaches have almost none. In all these conflicts clinical psychologists who are the leading figures in psychotherapy find themselves involved in harsh conflicts that weaken the status of professional psychotherapy. Psychiatrists from the administrative points of management and administration, social workers and other psychologists support minimal psychotherapy training for many professionals other then the 3 leading therapeutic professions. This condition makes it possible for many other professionals (occupational therapists, counselors, nurses, GP) to "sneak" in between and gain some training in psychotherapy. II. Future Prospects of the Psychotherapeutic Professions 4. Factors instigating change in the psychotherapeutic professions. As mentioned before, there is a planned reform in mental health services, initiated by the government. This reform aims at transferring the responsibility for mental health services to health insurance companies. The 4 major insurance companies (HMO's) are willing to take over this responsibility only if payment by the government or the public will be similar to the rates in private practices. In designing this reform plan, many decisions had to be undertaken, regarding length of treatment, treatment manuals, etc. Unfortunately, most of the decision
7 7 making processes are intuitive or political rather then evidence or research based. In this process, clinical psychologists who practice psychodynamic therapy are under severe threats: psychodynamic therapies are considered as very long, costly, with relatively little evidence of successful outcome. Mental health practitioners, decision makers as well as the public know very little about research findings, and therefore most of the decisions taken not based on sound clinical knowledge, but rather on partial research evidences and genera statements. 5. Basic skills required for training and practice in the psychotherapeutic professions. There is currently a harsh debate among the psychology departments at the universities about the appropriate curriculum for clinical psychology: some demand basic clinical core studies with an addition of specialty courses, such as: treating children, working with PTSD, psychotherapy for special populations, etc. Some believe that professional development and maturation can take place only in non- academic settings. We are concerned by the dangers and damages caused by so-called professionals who practice therapy with no basic professional grounding. 6. Relation of psychotherapy research to the psychotherapeutic professions. In Israel psychotherapy research is quite limited, and almost unknown. Researchers in psychology departments are concerned mainly with cognitive processes or social psychology, whereas clinicians in the field and in the academia- are not interested in research and do not see it as relevant to their practice. Research in psychodynamic psychotherapy is barely done. Still few outcome and process research projects on shortterm dynamic psychotherapies, attachment theories, CCRT, and other psychotherapy issues are carried out by 7 of Israeli members of SPR and few other psychologists and their students. Most graduate programs do not offer courses in psychotherapy research. Recently new faculty members, returning from graduate studies in the US to Jerusalem
8 8 and Be-er Sheva Universities have introduced research in CBT. and other therapies, as well as psychotherapy research seminars. Clinicians in the field read mainly psychoanalytic journals or psychotherapy journals focusing on case studies or theoretical reviews. There is very little exposure to research journals, such as JCCP, JCP pr Psychotherapy Research. Psychodynamic therapists and psychoanalysts are not familiar with research on psychodynamic therapy. Clinical decisions in many outpatient clinics and in private practice rely on therapists' clinical experience and supervision. Little consideration is given to research evidence supporting specific treatments for specific conditions. This is beginning to change in the past few years, with CBT gaining popularity, and other forms of specialized treatments (e.g. somatic experiencing for trauma, EMDR). The psychology licensing board, which is a part of the Psychologists' registry, has not adjusted its professional requirements according to research evidence. There is a strong resistance to research within the psychodynamic community, as research is associated with CBT, and perceived as superficial ("what can these numbers tell you that you don't already know?, and how can they capture complex psychodynamics processes?"). Psychotherapy research is perceived as contradicting the nature of psychodynamic therapy; therapy is based on deep elusive unconscious processes- whereas research focuses on conscious and intellectual processes. In addition, the procedures involved in psychotherapy research (e.g., taping sessions, administering self-report questionnaire, etc.) are perceived as disrupting the therapy process. There is little co-operation between the field and clinical researchers who are not part of the system, so that it is difficult to conduct psychotherapy research in collaboration with the field.
9 9 Grants and other types of funding are quite limited in this area. A new movement of clinical psychologists, trained in the US, has recently been formed, in order to advance EBP. Most of the therapists in this group practice CBT or family therapy. There are some psychodynamic members- however they are the minority. HMO's are currently looking into research studies in order to cut costs, find out what is cost-effective therapy, searching for various research questionnaires (e.g. Ministry of Health and the OQ validation project). Future perspectives: There is a strong pressure on the licensing board of clinical psychologists to adjust its requirements for the licensing exam (for interns) introduce more EB tools, and drop old psychodiagnostic testing methods that have low reliability and validity (e.g., debate about the efficacy and validity of the Rorschach). The topic of psychotherapy research is beginning to find its way into graduate courses and to be presented in local conferences. Encourage more dissertations in the area of psychotherapy research. Some interest in integrating research questionnaires into the routine practice of outpatient clinics. In perspective of the reform in mental health services mentioned above, and the processes of privatization of mental health services, the chances for psychotherapy research decrease.
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