This feature by Shamshy Schlager, PsyD is Part 2 of 2 in a series about practicing DBT in Israel. In the first part, Shamshy shares his initial journey with DBT and his motivations for setting up a practice in Israel. Here in part two, Shamshy shares what he encountered as he began to establish a DBT practice in his new cultural setting.
Prior to arriving in Israel, I had learned that there was a limited number of practitioners and teams that provided comprehensive and adherent DBT. This was not surprising at that time. Given the relatively small population, as well as distance and language barriers, there were few practitioners who could have plausibly had the opportunity to receive exposure to intensive and/or immersive training. In recent years, there has been more of a framework for advancing DBT in Israel by advocates such as Shani Avin, PhD and Helene Sher, MD, official Ambassadors to Behavioral Tech Institute, but this was not well established prior to my own move.
Another variable impacting the development of DBT in Israel relates to the emphasis on a psychodynamic training approach. While behaviorally-oriented therapy and training is becoming more common, the primary mode of therapeutic training in Israel remains psychodynamic, which may also serve to influence the appropriate and effective employment of DBT treatment. This may be further influenced by a belief among some practitioners that the principles and guidelines of adherent DBT will not translate to the Israeli client population, which I have not found to be the case. In addition, there are clinicians with good intent who seek to provide adherent DBT, but work as sole practitioners and do not have the ability to provide the treatment with the necessary components of individual therapy, skills group, phone coaching, and a consultation team.
Limited exposure and training in DBT or evidence-based practice can also impact the ability to add new team members, which as a clinical director I have personally experienced. Nevertheless, there are places where adherent DBT treatment exists or is developing, and I have learned that there is a strong desire for training and treatment dissemination among both the population and clinicians.
Determining the best pathways for clients to access adherent DBT and for the treatment to be disseminated in a coherent and responsible manner is a necessity of the highest order. Israel houses a diverse population of communities of people who speak exclusively or primarily Hebrew, English, or Arabic. I personally speak a generally fluent Hebrew that allows me to function with relative comfort in my day-to-day life. Combined with the fact that Israelis with a strong educational background speak fluent or capable English, educating and training future clinicians seems doable. However, I have personally found that successfully employing a treatment as sophisticated as DBT (in both individual therapy and group) with high-risk clients requires a precision of language and nuance well above fluency. It is important to find a pathway for aspiring clinicians and treatment communities to access high quality training in order to treat their respective clientele in a manner that is both culturally and linguistically appropriate.
Findings from The Ministry of Health indicate that every year more than 500 people commit suicide in Israel and more than 6,000 people per year attempt suicide. For several years, suicide has been one of the leading, if not the leading, cause of death in the Israeli military. Analysts further believe that there is under-reporting of approximately 23% in the numbers mentioned. Immigrant populations, such as my own, appear to be particularly vulnerable, with new immigrants reportedly accounting for one-third of all suicides.
These statistics highlight a concerning problem. Israelis are unfortunately accustomed to states of uncertainty and apprehension about the prospect of terror and war. The Israeli condition necessitates that one maintain one’s quality of life even in the midst of life-threatening concerns, a state of being that frequently tests DBT’s target hierarchy. However, the prospect of death and trauma outside of war or terror represents a threat to which Israelis may be less accustomed. Clients and clinicians alike are faced with the reality that 21st century life, and certainly adolescence, is more intense and foreboding than anyone might have expected. As in the time of Abraham Lincoln, we are learning that “the dogmas of the quiet past are inadequate to the stormy present” and that a more robust and well-trained community of therapists is required to attend to the needs of our community of clients.
While there is much work to do on a macro level, the day-to-day experience of working with clients, their families, and our treatment team is focused and personal. As in the US, there is a community of clients in Israel that is currently experiencing difficulties that inhibit their ability to identify and meet their aspirations in an ever-changing world. Greater access to training will provide clinicians with a broader framework and capacity to help their clients develop the practical tools for leading more compelling and fulfilled lives.
Shamshy Schlager, PsyD is a licensed clinical psychologist both in Israel and New York and founder and director of Modi’in Behavioral. He specializes in Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT), which are the gold-standard, evidence-based approaches for treating a variety of clinical disorders.
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