“We need actions, not words”: the perspectives of Russian-speaking immigrant families on recovery-oriented mental health care in Israel

The paper explores the patterns of coexistence of alternative/complementary health care (CAM) and conventional medicine in Israel in the cultural, political, and social contexts of the society. The data are drawn from over ten years of sociological research on CAM in Israel, which included observation, survey research, and over one hundred in-depth interviews with a variety of CAM practitioners - many with bio-medical credentials - and with policy makers in the major medical institutions. The analysis considers the reasons for CAM use, number of practitioners, the frequency of CAM use and some of its correlates, and how CAM is regulated. The structure of the relationship between the conventional health care system and CAM is discussed in the public sector, which provides two-thirds of CAM services, and in the private sector, which provides about one-third. The history of the development of these structures and some of the dilemmas of their operation are discussed. A number of policy issues are considered against this background: regulation and licensing, CAM in primary care, reimbursement for CAM treatment, and the inclusion of CAM in education and training for the health professions.

Introduction Recovery-oriented mental health services are being implemented in various countries; however, health workers still need to understand the concept, highlighting the need for a standardized definition of recovery to translate it into practice. To implement recovery-oriented care, it is crucial for healthcare workers to understand it first. The Recovery Knowledge Inventory (RKI) tool has been widely used to measure understanding of recovery in different countries. Therefore, the aim was to assess nurses' knowledge of a recovery-oriented mental health care approach using the RKI. Methods The study utilized a cross-sectional quantitative design. One hundred and fifty-two (152) nurses consented to participate in the study. The RKI was used to assess knowledge of a recovery-oriented mental health care approach in four mental health facilities across Botswana. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 27. Cronbach's alpha was used to test the reliability of the variables used in the study. Some variables that would compromise the overall reliability of the questionnaire were excluded. Following the reliability test, exploratory factor analysis (EFA) was used to explore the possibility of factors describing recovery-oriented mental health care. Results The sample included 81 (53.3%) female and 71 (46.7%) male nurses. The results indicated that after validity and reliability tests were conducted, and with some adjustments, the RKI was valid and reliable for assessing nurses’ knowledge of a recovery-oriented mental health care approach in Botswana. Although its reliability was average at Cronbach's alpha 0.6, it offered insight into how respondents perceived recovery. Most respondents (97%) agreed with the nonlinearity of recovery, while 84.9% strongly agreed or agreed that recovery from mental illness could be achieved by following a set of procedures. Overall, nurses in this study lacked orientation to recovery-oriented services. Conclusion There was a clear lack of knowledge of the recovery approach among the respondents. This study underscores the need for targeted training to improve nurses' understanding of recovery-oriented practices.

Health and health care in Israel: an introduction

The extension of academic censorship on Palestine to the medical world is, despite its pervasiveness, relatively unknown. In the latest iteration, a letter highlighting the Gaza Strip's vulnerability to the Covid-19 pandemic was removed from The Lancet's website after a swift pressure campaign. While the immediate effects were minimal — despite its short shelf-life, the piece is among the top 5% most discussed research publications11 "Overview of attention for article published in The Lancet, March 2020: Structural violence in the era of a new pandemic: the case of the Gaza Strip," Altmetric, https://www.altmetric.com/details/78453242. — the chilling effect of such campaigns on writers and editors is profound and enduring. This commentary outlines the struggle to make space for discussion and academic inquiry into the health impacts of the ongoing suffering inflicted on the Palestinian people. As Palestinians marked Land Day on March 30,22 Yara Hawari, "Commemorating Land Day amid lockdown in Palestine," Al Jazeera, March 30, 2020, https://www.aljazeera.com/indepth/opinion/celebrating-land-day-lockdown-palestine-200329162501923.html. The Lancet, one of the world's oldest and most prestigious medical journals, silently removed from its website a commentary that was published three days prior.33 The original piece is still available from ScienceDirect at the following link: David Mills, et al., "Structural violence in the era of a new pandemic: the case of the Gaza Strip," The Lancet, March 27, 2020, https://www.sciencedirect.com/science/article/pii/S0140673620307303#!. At just over 400 words, "Structural violence in the era of a new pandemic: the case of the Gaza Strip," draws on the deep historical and political forces that have rendered the Palestinian people in the Gaza Strip particularly susceptible to an impending Covid-19 outbreak. Mirroring numerous warnings that continue to be published elsewhere, including a statement by 20 Palestinian, Israeli, and international health and human rights organizations,44 Adalah – The Legal Center for Arab Minority Rights in Israel, et al., "Palestine: a possible COVID-19 epidemic in the Gaza Strip," Medecins Du Monde, April 8, 2020, https://www.medecinsdumonde.org/en/news/moyen-orient/2020/04/08/palestine-possible-covid-19-epidemic-gaza-strip. our commentary highlights the impact of pandemics on "populations burdened by poverty, military occupation, discrimination, and institutionalised oppression." Its critical tone is consistent with other Lancet commentaries targeting various national and global responses to Covid-19.55 Richard Horton, "Offline: COVID-19 and the NHS—"a national scandal"," The Lancet 395, no. 10229 (2020): 1022 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30727-3/fulltext; Sarah L. Dalglish, "COVID-19 gives the lie to global health expertise," The Lancet 395, no. 10231 (2020): 1189; https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30739-X/fulltext. While hoping the swift removal was just a technical error, our experience working on Palestine made us suspect otherwise. A hint came via the elated tweet of a Canadian endocrinologist who had been involved in prior efforts to censor scholarship connecting Israel's occupation and human rights abuses to Palestinian health outcomes. The next day we understood the impetus behind the commentary's sudden disappearance: a message had been circulated to the scientific community in the United States (and beyond) calling — ironically, given the hostility to similar boycott calls directed at Israel — for a boycott of The Lancet for publishing the piece. To understand The Lancet editorial staff's swift decision to remove the commentary, we need to go back to 2014. At the height of Israel's large-scale military assault on the Gaza Strip, The Lancet published "An open letter for the people in Gaza,"66 Paola Manduca, "An open letter for the people in Gaza," The Lancet 384, no. 9941 (2014): 397–398; https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61044-8/fulltext. setting off an aggressive years-long campaign with demands that both the open letter and the editor-in-chief be removed. Neither occurred after a thorough review by The Lancet ombudsman. The controversy culminated, however, with five 2017 Lancet Series papers designed to "outline Israel's achievements in health and health care."77 "Health in Israel," The Lancet, May 8, 2017, https://www.thelancet.com/series/health-in-israel. While the papers commemorated one of the world's most efficient healthcare systems,88 Lee J. Miller and Wei Lu, "These are the economies with the most (and least) efficient health care," Bloomberg, September 19, 2018, https://www.bloomberg.com/news/articles/2018-09-19/u-s-near-bottom-of-health-index-hong-kong-and-singapore-at-top. missing was any discussion of Israel's institutionalized oppression over the Palestinian people that leaves millions without the ability to develop or even access similarly exemplary healthcare. Indeed, the authors of the introductory piece of the series decided to "not comprehensively address historical or political issues, except when directly pertaining to health,"99 A. Mark Clarfield, "Health and health care in Israel: an introduction," The Lancet 389, no. 10088 (2017): 2503–2513; https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30636-0/fulltext. as if there were any other comparably important factors determining the stark health (and other) inequities between Israeli-Jewish and Palestinian inhabitants of the region.1010 Ido Efrati, "Huge disparities between Israeli, Palestinian health-care [sic] systems, says rights group," Haaretz, January 10, 2015, https://www.haaretz.com/.premium-huge-disparities-between-israeli-palestinian-health-care-1.5358335; "Concluding observations on the combined seventeeth to nineteenth report of Israel," Committee on the Elimination of Racial Discrimination, December 12, 2019, https://tbinternet.ohchr.org/Treaties/CERD/Shared%20Documents/ISR/INT_CERD_COC_ISR_40809_E.pdf. The aftermath of the publication of the 2014 letter explains how The Lancet, a high-profile outlet courageously and almost uniquely willing to cover the political and historical forces impacting Palestinian health, came to publish an entire edition—perhaps the most prominent example of "healthwashing"—that sweeps these defining issues under the rug. "An open letter for the people in Gaza" denounced Israel's 2014 military assault on the besieged Gaza Strip, highlighting the widespread killing and severe injury of Palestinian civilians, including children. Noted was the extraordinary loss of infrastructure, leaving more than 100,000 people homeless,1111 "4.5 years after Israel destroyed thousands of homes in Operation Protective Edge: 13,000 Gazans still homeless," B'Tselem, March 3, 2019, https://www.btselem.org/gaza_strip/20190303_13000_gazans_homelsess_since_2014_war. and the dramatic impacts of Israel's ever-tightening blockade on access to essential medicines, food, and potable water. The authors criticized the complicity of third states, as well as that of Israeli health professionals who failed to speak out against this massacre.1212 Ido Efrati, "Israeli docs mobilize against anti-Israel letter in The Lancet," Haaretz, July 28, 2014, https://www.haaretz.com/docs-target-anti-israel-letter-in-the-lancet-1.5257147. Precisely the same complicity was noted in a Lancet editorial following Israel's 2008–2009 military assault on the Gaza Strip.1313 "The medical conditions in Gaza," The Lancet 373, no. 9659 (2009): 186; https://www.thelancet.com/jour-nals/lancet/article/PIIS0140-6736(09)60049-0/fulltext. The journal's editors deplored the "silence of national medical associations and professional bodies worldwide in response to this destruction and dislocation of health services," singling out medical association leaders, who "through their inaction, are complicit in a preventable tragedy that may have long-lasting public-health consequences not only for Gaza, but also for the entire region." Within a context of pervasive Israeli impunity,1414 "Resolution adopted by the Human Rights Council on 22 March 2019," UN Human Rights Council, April 3, 2019, https://documents-dds-ny.un.org/doc/UNDOC/GEN/G19/096/44/PDF/G1909644.pdf?OpenElement. the 2009 and 2014 Lancet statements were — and remain — bold calls for action. Each historical juncture was accompanied by an expectation that now, finally, the world should stand up and address the root causes prolonging the injustice and suffering of the Palestinian people. While this ultimately did not occur, The Lancet offered readers the option of adding their signatures to the 2014 letter;1515 "Smear campaign against The Lancet's "Open Letter" on crimes against humanity in Gaza," Global Research News, April 19, 2015, https://www.globalresearch.ca/smear-campaign-against-the-lancets-open-letter-on-crimes-against-humanity-in-gaza/5443762. tens of thousands did so, signaling that a chord of outrage had been resonantly struck. But the extremeness of Israel's military actions in the summer of 2014 did not dilute the potency of the reactionary outcry from its defenders the world over. The response to The Lancet letter took two main forms. First, there was a slew of letters and email invective launched at The Lancet, generally, and at the journal's editor-in-chief, Richard Horton, in particular. And not just Horton, who was vilified as an anti-Semite with a photo of a uniformed Nazi conjoined to his.1616 Ido Efrati, "After accusing Israel of war crimes, Lancet medical journal devotes entire issue to Israeli health care," Haaretz, May 10, 2017, https://www.haaretz.com/israel-news/lancet-devotes-whole-issue-to-israeli-health-care-1.5470008. The verbal abuse extended to his wife and school-age daughter, reminiscent of the vicious personal attacks on Judge Richard Goldstone following the 2009 release of his United Nations Fact Finding Mission report on the Gaza conflict, which included an attempt to ban him from attending his own grandson's bar mitzvah at a synagogue in Johannesburg.1717 Akiva Eldar, "What exactly did Goldstone 'retract' from his report on Gaza?" Haaretz, April 11, 2011, https://www.haaretz.com/1.5150611. The harassment of medical editors who publish material critical of Israel's policies and actions long predates the modern siege on the Gaza strip. In 1981, the editor of World Medicine, Michael O'Donnell, was targeted in a similarly aggressive campaign, ultimately leading to his dismissal and even the dissolution of the journal. What O'Donnell makes clear in his 2009 chronicling of the 1981 attacks, is that these are not spontaneous outcries of protest, but carefully orchestrated lobbying campaigns designed to obscure the truth about Israel's systematic denial of Palestinian rights. The goal is not only to silence editors but to inhibit would-be writers, many of whom reasonably fear professional and personal consequences. "The technique has endured for decades because it is effective," O'Donnell writes,1818 Michael O'Donnell, "Commentary: standing up for free speech," British Medical Journal 338 (2009): a2094; https://www.bmj.com/content/338/bmj.a2094?ijkey=a750758b30f7cd89d23d514cec8fb8d995e8475d&keytype2=tf_ipsecsha. and if this reemergence in 2020 has any lasting significance, it will be to test and challenge whether this remains so. The second type of response to the 2014 letter came in the form of tacit mobilization of powerful interests to limit free speech on the health impacts of Israeli policies and practices. These tactics are by now well-known outside the medical world,1919 Ben White, "Delegitimizing Solidarity: Israel Smears Palestine Advocacy as Anti-Semitic," Journal of Palestine Studies 49, no. 2 (2020): 65. https://online.ucpress.edu/jps/article/49/2/65/107373/Delegitimizing-Solidarity-Israel-Smears-Palestine?searchresult=1; "UN rights experts denounce Israel's growing constraints on human rights defenders," OHCHR, March 3, 2017, https://documents-dds-ny.un.org/doc/UNDOC/GEN/G19/150/38/PDF/G1915038.pdf?OpenElement. falling within the broader context of concerted efforts led by the Israeli government to outlaw Palestine solidarity and delegitimize human rights defenders, organizations, and activists who challenge Israel's abuses and seek justice and accountability.2020 "Israel / Occupied Palestinian Territory: ongoing smear campaign against Al-Haq staff members Mr. Shawan Jabarin and Ms. Nada Kiswanson," International Federation for Human Rights, November 10, 2017, https://www.fidh.org/en/issues/human-rights-defenders/israel-occupied-palestinian-territory-ongoing-smear-campaign-against. In January of 2015, explicitly identifying the 2014 letter to The Lancet as the motivator,2121 "ADA/AACE/EASD/TES Statement in Response to a Recently Published Letter to the Editor in The Lancet and an Editorial Addressing the Israeli-Palestinian Fighting in Gaza," PR Newswire, November 3, 2014, https://www.prnewswire.com/news-releases/adaaaceeasdtes-statement-in-response-to-a-recently-published-letter-to-the-editor-in-the-lancet-and-an-editorial-addressing-the-israeli-palestinian-fighting-in-gaza-281311631.html. the Presidents of the American Diabetes Association, the European Association for the Study of Diabetes, the American Association of Clinical Endocrinologists, and the Endocrine Society, as well as the editors-in-chief of eight diabetes and endocrinology journals, issued a statement of principle that proclaimed "our respective journal will refrain from publishing articles addressing political issues that are outside of either research funding or health care delivery."2222 "Statement of principle," American Diabetes Association, Diabetes 64, no. 1, (2015): 311; https://diabetes.diabetesjournals.org/content/64/1/311.full-text.pdf. Leaving aside the oddness of diabetes professionals' unwillingness to publicly tackle the political factors that drive the disease in which they specialize — a position even more untenable as the Covid-19 pandemic exposes the political underpinnings of health with drastically inequitable infection and mortality rates2323 Zeeshan Aleem, "New CDC data shows Covid-19 is affecting African Americans at exceptionally high rates," Vox, April 18, 2020, https://www.vox.com/coronavirus-covid19/2020/4/18/21226225/coronavirus-black-cdc-infection. — an ethical question lingers here. Should physicians and scientists be permitted to publicly narrate the historical, structural, commercial, social, and political forces that lead to avoidable death, illness, and suffering? Given the clear link between these forces and ill health, and the consensus that ignoring them leads to worse outcomes,2424 Seth M Holmes, et al., "Misdiagnosis, Mistreatment, and Harm - When Medical Care Ignores Social Forces," The New England Journal of Medicine 382, no. 12 (2020): 1083–1086; https://www.nejm.org/doi/full/10.1056/NEJMp1916269. might it not be their duty, in fact, to do so? Such questions recall Edward Said's influential 1984 paper, "Permission to narrate,"2525 Edward Said, "Permission to Narrate," London Review of Books, February 16, 1984, https://www.lrb.co.uk/the-paper/v06/n03/edward-said/permission-to-narrate. in which he juxtaposes the historically uncontested facts of Israeli aggression during the 1982 Lebanon War with the perception in Western media that Palestinians were the primary wrongdoers and agents of violence. "Sequence, the logic of cause and effect as between oppressors and victims, opposing pressures—all these vanish inside an enveloping cloud called 'terrorism,'" Said notes. The narrative is distorted beyond recognition, and "there is every chance that ignorance about Israel's attitude towards Palestinians will keep pace with sustained encomia on Israel's pioneering spirit, democracy and humanism." Particularly when silencing comes within the context of prolonged violations of international law and institutionalized impunity,2626 Jonathan Cook, "Israel is silencing the last voices trying to stop abuses against Palestinians," Mondoweiss, November 12, 2019, https://mondoweiss.net/2019/11/israel-is-silencing-the-last-voices-trying-to-stop-abuses-against-palestinians/; "Israel: Supreme Court Greenlights Deporting Human Rights Watch Official," Human Rights Watch, Press Release, November 5, 2019, https://www.hrw.org/news/2019/11/05/israel-supreme-court-greenlights-deporting-human-rights-watch-official. medical journals have a heightened responsibility to narrate facts within what Said describes as a "socially acceptable narrative to absorb, sustain and circulate them."2727 Edward Said, "Permission to Narrate," London Review of Books, February 16, 1984, https://www.lrb.co.uk/the-paper/v06/n03/edward-said/permission-to-narrate. In order to avoid the primacy of ideology over scientific inquiry, publishers must allow for pertinent critique of powerful entities, including states, a willingness Richard Horton has demonstrated frequently during his tenure at The Lancet.2828 Richard Horton, "Offline: COVID-19 and the NHS—"a national scandal,"" The Lancet 395, no. 10229 (2020): 1022. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930727-3; Yair Amikam, "The Palestinian Medical Crisis: An Exchange," The New York Review of Books, June 14, 2007, https://www.nybooks.com/articles/2007/06/14/the-palestinian-medical-crisis-an-exchange/. With the systematic silencing of voices critical of Israel's violations and refusal to acknowledge a Palestinian counter-narrative, a perspective that highlights the primacy and consequences of Israeli aggression will seem outrageous to many, in 2020 as much as in 1982 or in the aftermath of Palestinian expulsion during the Nakba ("catastrophe") of 1948. In prominent medical journals, Palestinian health narratives feature infrequently. When surveying the literature, the most prominent medical journals in the United States have only one mention of Palestine for every 20 mentions of Israel, compared with a still lopsided one-to-four ratio for leading medical journals in the United Kingdom.2929 Mads Gilbert, "Publication Patterns on Occupied Palestine in Four Key Medical Journals 1990–2016: A Descriptive Study," The Lancet 391 (2018): S24. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30390-8/fulltext. While one could argue that this reflects a lack of research production from Palestine, which would require its own thoughtful explication, our experience—both recent and historic— suggests this represents a refusal of academic space for those who challenge dominant, ideologically-motivated health narratives. In its willingness to elide uncomfortable historical and political realities,3030 Gideon A. Paul, et al., "A Call for Academic Medicine to Remain Politically Neutral," The Lancet 393, no. 10183 (2019): 1806. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30027-3/fulltext. the medical association-sponsored silence on Palestine confirms this suspicion, implying a penchant for ideology rather than pursuit of truth in approaches to understanding health. What else could motivate a statement promoting censorship of the root causes of disease? Tellingly, the physicians and scientists who pounced on The Lancet following the publication of our latest piece didn't bother to submit a reasoned reply for the journal's consideration, perhaps because some had already declared "victory" in the journal's pages last year. In a triumphant letter,3131 Julio Rosenstock, et al., "Bringing Closure: Towards Achieving a Better Understanding of Israel," The Lancet 394, no. 10198 (2019): 559. https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(19)31760-X.pdf. ironically political given it was led by a board member of the American Diabetes Association (who is also an associate editor of a journal involved in the aforementioned statement of principle),3232 "Statement of principle," American Diabetes Association, Diabetes 64, no. 1, (2015): 311. https://diabetes.diabetesjournals.org/content/64/1/311.full-text.pdf. the authors celebrated the success of their self-described "sanctions" against The Lancet. Remarkably, when asked whether their boycott of The Lancet weakened the case against boycott of Israel, one of them said, "We had no other option."3333 Peter Kohn, "Pro-Israel doctors end dispute with The Lancet," Australian Jewish News, August 15, 2019, https://ajn.timesofisrael.com/pro-israel-doctors-end-dispute-with-the-lancet/. In addition to the proven historical efficacy of the systematic bullying and censorship touted and euphemized in their letter, there is another plausible reason for avoiding academic debate on our commentary's claims. It is almost certain that none of those lashing out at the journal, neither in 2014 nor today, have meaningful experience living with Palestinians or working on health and human rights in Palestine. On which other topic are the inexperienced and unequipped allowed such sway in the worlds of science and health? And if, despite the experiential gap between us, they wish to press on, shouldn't they have to do so with the same platform available to us—that of reasoned discourse? This isn't just an ivory tower discussion on academic freedom. If the scientific and medical communities refuse to take a strong stand on censorship, bullying, and aggressive lobbying campaigns aimed at silencing academic journals, the well-deserved fear of even the most sympathetic editors—who deserve our staunch solidarity—will allow for the continued erasure of Palestinian health facts, voices, narratives, and experiences. In "Structural violence in the era of a new pandemic: the case of the Gaza Strip," we that violence in historical, and health and that the and response to disease At a when Palestinians are exceptionally susceptible to the Covid-19 the of this ongoing silencing campaign could not be are in the and medical and scientific communities of should that of censorship must be not

This report reviews the quality of health care in Israel. It begins by providing an overview of the range of policies and practices and the role they play in supporting quality of care in Israel (Chapter 1). It then focuses on three key areas: strengthening community based primary care (Chapter 2), tackling inequalities in health and health care (Chapter 3), and improving care for people living with diabetes (Chapter 4). In examining these areas, the report seeks to highlight useful practices and provide recommendations to improve the quality of health care in Israel.

This study examines Hirschman's model of exit, voice and loyalty with regard to informal payments in the Israeli healthcare system. Based on a national survey, we investigate the extent of "black" payments, its characteristics and its correlated factors. We find that informal payments do exist in Israel-although it seems that there has been a decline in the phenomenon. Contrary to the literature, we find no relationship between the option of voice or dissatisfaction with healthcare services and informal payments. However, we do find a negative correlation between trust and the use of such payments. This finding is consistent with Hirschman's insight that a lack of loyalty may lead people to strategies of exit. We suggest that given the fact that health care in Israel is a public service, the exit option may actually be a quasi-exit behavior. Copyright © 2015 John Wiley & Sons, Ltd.

Despite increased interest in relationships and emotions in social work, not enough is known about the role of emotions in recovery-oriented mental health care settings. Reflecting on my graduate research, I explore the inconsistent understandings and comfort levels with emotions in mental health social work practice. I make connections with findings which show that uneven attempts at relationship-building lead to missed opportunities for connection, understanding, and supporting recovery. I discuss the tensions faced by mental health practitioners implementing recovery-oriented interventions within a new public management and risk reduction paradigm of care and the ways that attending to emotions might help critique or dismantle the status quo. These reflections suggest pathways to resist these tensions through realizing the potential of emotions as a source of knowledge in constructing recovery-oriented mental health care interventions.

Leadership and mental health recovery: Rhetoric or reality.

Contents Social Work in Mental Health: Trends and Issues* Recovery and Empowerment for People with Psychiatric Disabilities * Community Care and the Origins of Psychiatric Social Work * Strategies for Helping Young Adults with Severe Mental Disorders * Social Networks and Psychological Disability Among Housed and Homeless Users of Self-Help Agencies * Discharge Planning and Community Housing in Ontario * Working Collaboratively with Families * The Universality of Self-Help Program of American Origin: Narcotics Anonymous in Israel * The Ethics of Informed Consent: A Critical Variable in the Self-Determination of Health and Mental Health Clients * Revamping Mental Health Care in Israel: From the Netanyahu Commission to National Health Insurance Law * Index

A two-month visit to the Chaim Sheba Medical Center, Tel-Hashomer, Israel, provided an opportunity to investigate some aspects of that country's health care system. Observations on the Israeli health care system and on the populations served, with highlights on cultural, demographic, political, and historic factors, are essential to an understanding of health care in Israel. A detailed description of the organization and administration of services at the Chaim Sheba Medical Center may aid in this understanding. It is essential to our understanding of this health care system to realize that Israel is not a purely Western nation. To gain insight into the system, we must consider the nation's political and economic situation. Such an awareness is crucial to the study of any foreign health care system.

A two-month visit to the Chaim Sheba Medical Center, Tel-Hashomer, Israel, provided an opportunity to investigate some aspects of that country's health care system. Observations on the Israeli health care system and on the populations served, with highlights on cultural, demographic, political, and historic factors, are essential to an understanding of health care in Israel. A detailed description of the organization and administration of services at the Chaim Sheba Medical Center may aid in this understanding. It is essential to our understanding of this health care system to realize that Israel is not a purely Western nation. To gain insight into the system, we must consider the nation's political and economic situation. Such an awareness is crucial to the study of any foreign health care system. (<i>JAMA</i>239:2355-2358, 1978)

The meaning of patient satisfaction with prepaid primary health care in Israel

Objective-Persons with severe mental illness have higher rates of chronic general medical illness compared with the general population.Similarly, compared with the general population, incarcerated persons have higher rates of chronic medical illness; however, there is little information about the synergy between severe mental illness and incarceration and the general medical problems of consumers.To address this gap in the literature this study addresses the following question: are consumers with a history of incarceration at greater risk of general medical problems compared with consumers without such a history?Methods-Administrative data were used to compare the medical problems of 3,690 persons with severe mental illness with a history of incarceration and 2,042 persons with severe mental illness with no such history.Results-Consumers with a history of incarceration were more likely than those with no such history to have infectious, blood, and skin diseases and a history of injury.Furthermore, when analyses controlled for gender, race, age, and substance use disorders, consumers with an incarceration history were 40% more likely to have any general medical problem and 30% more likely to have multiple medical problems.Conclusions-The findings presented here call for better communication among local public health and mental health providers and jails and better integration of primary care and behavioral health care among community mental health providers.Also, research on evidence-based interventions designed to divert persons with severe mental illness from the criminal justice system and facilitate community reentry for persons with severe mental illness who are released from jails and prisons should be accelerated.

With the increasing emphasis on evidence-based practices and recovery-oriented mental health services, the field of psychosocial rehabilitation for people with serious mental illness has a promising future. A tension exists in the rehabilitation movement--which comprises individuals with mental illness, care providers, family members, and other stakeholders--between those who advocate for recovery leading to full participation in the mainstream and those who call for more modest goals. This tension stems from ideological underpinnings that frequently drive debates about rehabilitation research and program development. This Open Forum proposes a strategy for clinicians to mediate the different perspectives, with an emphasis on flexibility and an individualized approach to clinical care and rehabilitation. The challenges and rewards of this approach for clinicians in training are also highlighted.

Patient-centered communication has been linked to patient satisfaction, treatment adherence and outcomes. Shared decision making (SDM) has been advocated as an important and ethically essential aspect of patient-centered care, but SDM has received relatively little attention in mental health care, despite studies indicating that consumers want to be involved in making decisions. This is particularly important in a recovery-oriented system, where consumers are active participants in their treatment and rehabilitation. Because medication management is a key component of recovery from severe mental illnesses, this study explores how consumers and providers make decisions in medication management consultations. Four providers (3 psychiatrists, 1 nurse practitioner) and 40 consumers with severe mental illness (10 consumers per provider) were recruited from a community mental health center with a recovery-oriented focus. We directly observed 40 medication management appointments. Observations were audio recorded and transcribed. We used emergent thematic analysis to characterize decision making processes. Providers initiated most decisions, although they often invited consumers to participate in decision making. Decisions initiated by consumers elicited a greater degree of discussion and disagreement, but also frequently resulted in consumers' preferences prevailing. Consultations generally exhibited more characteristics of person-centeredness than SDM. While we observed a high degree of person-centeredness, SDM was not prevalent. Interventions helping consumers to take greater initiative when working with service providers may be helpful. For example, programs using tools such as peer instruction, Internet-based software, and individual case-manager instruction all have shown promise for enhancing SDM in mental health treatment. Further research is needed to determine the degree of SDM in other settings (e.g., with case managers) and the impact of SDM on consumers' recovery.