The Children of Israel 5: A Requiem for Child Therapy

Psychotherapy for children was a significant and rather flexible set of procedures that were taken very seriously in the West from the early 20’s to the late 90’s of the 20th century, a period of about eight decades. For most of the latter half of this period there was considerable interest in child therapy in Israel.

While only the specialist can appreciate the differences between the different schools of child therapy, I would like to point out here the major similarities shared by most child therapists, particularly as they express a social attitude towards children.

  • The child is listened to with the utmost seriousness and respect as an individual.
  • Careful attention is given to the differences between how a child experiences and thinks and how adults experience and think.
  • The child is offered a deep and prolonged emotional relationship with a clinician who sees the world – including the home and the school – through the child’s eyes.
  • Deep respect is given to the child’s attachment to parents and their “return” from the therapeutic process to a deeper trust in her parents as far as possible.
  • The therapy assumes an optimistic view of child development, that is, that a child will move towards favorable development once obstacles to such development are overcome.
  • Therapy is directed towards development, and once development becomes more favorable it is assumed that the child will no longer require the therapy.
  • I once summarized some of these points in a reader on Therapeutic Communication with Children that was published by the Ministry of Welfare in 2002 in Hebrew. At the time I did not realize I was composing an obituary.

    Some decade and a half later, child therapy has become all but erased from the options available to Israeli Children. I will first describe the current situation factually and then attempt an analysis of the transformation.  The facts include three factors:

    1. The “Reformation” in Mental Health Services

    The new State of Israel made a political compromise in its establishment of health services. The dominant MAPAI  (Labor union) party assumed control of medical treatment services, according to Sutton’s Law (Willie Sutton, a notorious bank robber, when asked why he robbed banks answered famously and perhaps spuriously  “That’s where the money is.”) The socialist MAPAM party was given the Ministry of Health but was limited to preventive services. Some of the amusing results of this Kafkaesque arrangement can be found in my recent Losing It. Both sides were ambivalent about Mental Health, so it was divided down the middle. There were hospitalization and outpatient departments both in the MAPAI based Kupat Holim (HMOs) and in government facilities.

    For about four decades the fledgling State of Israel struggled to provide what was then considered proper mental health services for children. The Ministry’s Tipat Halav (“A Drop of Milk”) program assessed emotional development in early childhood. The Kupat Holim and Government clinics attempted to apply the state of the art treatments for troubled children. The Israel Institute of Psychoanalysis in Jerusalem maintained close ties with Anna Freud, one of the founders of child therapy and attempted to apply her new insights in child development to the Israeli context of mass immigration and recurrent trauma.

    For the last decade at least, all sides have been busy trying to get out of the mental health business. It should be noted that current PM Netanyahu, in his first brief stint as PM in 1996-98 actually made an aborted attempt to create an American model (already globally recognized as a catastrophe) which would undermine universal health care and create non-insured populations. Since that time the government has consistently expressing its plan to cease to serve as a provider of mental health services. The Kupot Holim (there are four major HMOs currently) were to receive a budget to either pick up all mental health services or to now purchase them from the government clinics. After more than a decade of “negotiations” and “planning,” the “reformation” became a reality just about one year ago. It quickly became clear that the HMOs had made no adequate provisions for mental health, let alone child mental health services, so that the “reformation” was widely considered a bluff and a mechanism to drastically reduce mental health services, especially those for children. In reality, for the past year children in need of significant mental health services often have absolutely nowhere to turn. It is no secret that none of the Kupot made any remotely adequate effort to train and recruit child therapists despite a decade “heads-up” on the change.

    1. The Silent Relocation of Child Mental Health into the Educational System

    For the last decade, the JDC (aka “Joint”) through its Ashalim division, engaged in a well-funded attempt to train guidance counselors to become mental health providers. For nearly ten years groups of about two dozen experienced guidance counsellors were given bi-weekly intensive training sessions with senior clinicians. The stated goal was to “empower” educational counsellors to diagnose and treat most emotional difficulties of school-age children. One publication based on yearly conferences of the program was entitled “The Strength of the Guidance Counsellor.”

    In parallel, but with no apparent coordination, the Education Ministry engaged in intensive training for Art Therapists who would find employment leading art therapy groups in the elementary schools. Here again senior clinicians were enlisted to create a cadre of clinically skilled therapists to treat mental health difficulties of children in the educational setting.

    When I relocated from New York to Beer Sheba in 1983, I set my purpose to create community mental health services for children in the Southern District. At the time, the established mental health providers gave such plans lip service alone and I left the public sector after less than two years of utter frustration. Some of the details of my experiences appear in Losing It. So one might imagine that when I was drafted into the training programs for what would on the surface appear to be a fulfillment of community services, I would feel greatly vindicated and fulfilled. This was to be only partly true. The guidance counsellors regularly pointed out that they did not have training as therapists, and that while they were glad to expand their skills to some extent, they required skilled mental health professionals with whom they could consult and to whom they could refer children and adolescents requiring more specialized care. Case after case that they presented in the training groups ran ashore when the participants realized that there were no such resources in the community available for such consultation or referral. Often trainees would state disappointment, at times indignation that they could well be trained to be a part of a community mental health network, but they could not expect to be the only part that actually existed.

    In a similar vein, the art therapists would regularly point out that their training and interest did not include making a clear diagnosis of the problem and that the generic group treatments that they could provide could well be a part of a community network, but could hardly be expected to be the only resource in existence. They also would regularly point out that not all children feel able to participate in mental health services within the school. The came to recognize – sometimes with no small prompting on my part – that the public move from class to “clinic” was not suitable for all children (for example they would hardly want their own children treated is such a manner), and that the need for “entry and re-entry” emotional transitions from therapy to education was not given proper attention in these programs.

    1. Changing Treatment Modalities

    The very notion of “therapy” has undergone a complete transformation in the past two and a half decades. A number of factors, some overt and some covert, converged to claim to cast doubt on the “evidenced based” efficacy of all the therapies that I described at the beginning of this report. While the absurd claim that drugs could make all other treatments superfluous could not be taken seriously regarding children, the no less absurd claim that short “cognitive-behavioral” treatments and parental guidance could become the sole modalities necessary to treat all emotional trouble in childhood now dominates most “professional” opinion. The “cognitive-behavioral” conundrum was simply imported from adult treatment with very little modification. Children’s anxieties, for example were supposed to quickly disappear once the child achieved the new “cognition” that it was he himself who was creating the anxiety from which he suffered, ergo he could equally well stop creating it. In these treatments, the superior cognitions of the clinician just need to be sown in the minds (and hearts, in the “emotionally based” CBTs) of the children, a rather straightforward and brief one-way procedure.

    In addition to the CBT modalities, “Parental Counseling” bore great appeal for clinicians who were uncomfortable with the face to face therapeutic encounter with the child. In Israel today there are three major factors that bolster the claims of this modality. First, many mental health personnel who are held institutionally responsible for improving the behavior of children – especially guidance counselors and educational psychologists – have never completed training in face to face therapy with children. These workers feel more secure in advising parents, mostly in a rather direct linear fashion. Second, the overwhelming majority of so-called family therapists in Israel have never completed training in child therapy. These clinicians prefer to adopt a family systems “concept” but a simplistic counseling practice because they do not feel secure with their therapeutic role when children are in the room.

    A few years back I was invited to address the Family Therapy Association about this strange vicissitude. Third, an extremely popular(istic) work by a respected clinician put forward the claim that “parental authority” in Israel, globally, was in urgent need of “rehabilitation.” This work contributed beyond expectation to a prevalent misconception that the parents are always the problem, usually because they are wimps. This led to enthusiasm for the simplistic and therefore highly marketable idea that in the counseling room parental authority somehow magically becomes rehabilitated by telling parents to do so, and then the kids just straighten out.

    Today a troubled child has very little hope of being treated in the public sector by anything resembling individual psychotherapy. The school most likely will be the source of complaint that the child may be emotionally troubled. The child may be referred to a school guidance counselor or (rarely) educational psychologist who will counsel the parents to be more authoritative or the child may be referred to an art therapy group that meets (publically) during school hours. The child could be referred to a Kupat Holim, where the treatment, if available at all in real developmental time, will be similar.

    If we examine the status of children in Israeli society as reflected by this shift in approach and practice, we will note six levels of change:

    1. The child is mostly irrelevant as an individual.
    2. The child is more or less expected to relinquish “childish” ways of experiencing reality and become more like the adults who determine her treatment.
    3. There are barely any clinicians who can offer a deep relationship and an attempt to see the world through the child’s eyes. The child is expected to see the world through adult eyes.
    4. Parents are treated as some variation of “loser” (a highly loaded and almost universal Israeli invective for anyone who disagrees with you) who requires the corrective counseling of “authority” experts, a.k.a. “winners.”
    5. Child development is seen as pessimistic; children will become recalcitrant unless properly restrained by adult authority.
    6. Therapy is focused on “appropriate” behavior, not on personal development.

    If the reader would care to substitute “the woman” for “the child,” she may note some support for my impression that women and children are often co-repressed.

    It is a popular opinion among experts, especially academics, that this change is the result of “science.” I would hope that anyone following this Blog series would at least chuckle at this claptrap. The “other than scientific” (i.e. social) “cause” or, better, “source” of the change may become more apparent if we examine this situation as a dispotif.  This is the term used by social critic Michel Foucault to describe the way things actually happen, as opposed to the stated intentions. (I considered this term more completely in Losing It.) The demise of personal therapy for children relies on several significant assumptions about the place of children in Israeli society today.

    1. Children have nothing to contribute to the way adults understand the world. A given child’s difficulty in adjusting to the adult-created world always signals a failing of the child, never a gap created by adults that could serve as a source of increased social understanding. Children either adjust to expectations or they need to be made invisible.
    2. There is nothing that adults can learn from the way children see the world. Adults are simply more mature, never, covertly childish as that fiend Freud suggested before he received the erasure he deserved. A child is never a mirror for an adult to recover some aspects of his emotional life that covertly guide him, including how he treats children [and women?].
    3. Relationships, let alone deeply mutual relationships, are an elective luxury in development. Children can adjust just be listening to their elders.
    4. Good parents have kids who listen to them and try to please them. A parent who listens to his kids is suspect of not providing adequate authority.
    5. Children are dangerous if not vigilantly supervised.
    6. Children need to be regimented, not pampered with individuality.

    If the reader feels like jumping out of her skin at this point,  shouting (I recommend whispering, my dear, especially if you still have kids at home) “WTF! That’s impossible. The State of Israel wants kids to just follow orders and be productive in roles that the State sets for them!?” Well, that is exactly the dispotif that Foucault suggested that the “Westphalian” (see previous Blogs) State implements. Silently, while claiming to do just the opposite. The State requires a population that gives the State security (IDF) and economy (Start-Up State). All that individual attention runs counter to this, especially when measured by the “Quarter,” which is more or less the measure of the self-proclaimed short and “evidence-based” treatments. In short, children who received deep personal therapy remained dangerous as unreliable citizens. Better to use “therapy” as another tool to keep potential citizens in line, adjusting to authority, accommodating to expectations, and accepting full blame (“responsibility”) for any imperfections in the underfunded and woefully neglected public education system. Don’t just learn computers, become one. When in need, an expert will come to fix your operating system and remove any individual bugs.

    Was there some evil conspiracy to turn therapy into control and children into robots? Of course not, that’s how a dispotif works. It is never “intended” by anyone. It is silent and invisible. Until you open your eyes, or listen carefully to a child.

    About the Author
    Alan Flashman was born in Foxborough, MA, and gained his BA from Columbia, MD from NYU, Pediatrics, Adult and Child Psychiatry specialties at Albert Einstein College of Medicine, The Bronx, NY. He has practiced in Beer Sheba since 1983, and taught mental health at Hebrew University, Tel Aviv University and Ben Gurion University. He is currently CEO of Family Instiute of Neve Yerushalyim, sponsoring a first fully accredited post-masters training in family therapy for the Haredi community. Alan has edited readers on Therapeutic Communication with Children (2002) and Adolescents (2005) in Hebrew, translated Buber's I and Thou anew into Hebrew, and authored Losing It, an autobiography, and From Protection to Passover.