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A Bird’s Eye View of Israel and Its History of Psychotherapy

The state of Israel was established in 1948. It was marked by massive immigration from Europe by absorbing survivors of the Holocaust (many of whom were the sole survivors of their families, like “a brand plucked from a burning tree”) and Jewish exodus from Arab and Muslim countries. From the very beginning, heterogeneity characterized its population – a multicultural society: Jews (Ashkenazi and Sephardi origin), Arabs (Muslim and Christian), secular, and religious. The vision of building a homeland for immigrants, many of whom were refugees, encouraged innovative projects to absorb newcomers, such as collective settlements, a universal health-care system, etc. In 1948, there were 800,000 inhabitants, and since then, the population has increased to about 9.3 million citizens in 2018. In regard to health care in Israel, the system is universal with “cradle to grave” coverage, and presently, all Israeli citizens are entitled to basic health care as a fundamental right based on the National Health Insurance Law of 1995 (Segel, 2009). In 2012, Mental Health Reform was introduced by means of the National Health Insurance order by the Minister of Health, “with the objective of transferring the responsibility of the provision of mental health services from the Ministry of Health to the HMOs. This change was aimed towards the planned unification of the system that offers treatment for bodily ailments and that which treats mental crises through the HMOs (Kupot Cholim)” (State of Israel, Ministry of Health, 2012).

In Israel, there is a high proportion of clinical psychologists who practice psychotherapy; furthermore, clinical psychology is high on the list of the desired professions. Typically, psychotherapy in Israel is practiced by clinical psychologists, social workers, and also art therapists, but to a lesser extent. Although many psychiatrists practice psychotherapy, there is an increased tendency among them to focus on biological treatments. Moreover, in recent years, CBT has been included in their syllabus and in the final examination in psychiatric specialization.

History of Psychotherapy in Israel

Historically , one can identify two basic kinds of psychotherapeutic orientations among Israeli psychotherapists. The first kind of psychotherapists view psychotherapy as a long process, not necessarily specified nor focused, aimed at increasing the person’s awareness of his or her emotions and motives and gaining insight into the origin of their problems. In a majority of cases, this approach does not include an evidence-based assessment tool neither at the beginning of therapy nor at its termination, while its goals are clearly not defined in resolving specific problems. The most representative examples of this kind of psychotherapy are psychoanalysis and existential psychotherapies. The second kind of psychotherapy practiced in Israel can be characterized as being more focused on specific issues followed by the diagnosis of the client’s presenting problem. These therapies include short-term psychodynamic psychotherapies of several varieties, Adlerian, strategic, hypnotic, biofeedback, family, behavioral, and cognitive therapies (Ronen & Rosenbaum, 2010). As can be seen from this description, in Israel, unlike the UK or the Netherlands, for example, in many cases (in the past and to a certain degree in the present), the path to becoming a CBT psychotherapist begins with psychodynamic training of clinical psychologists and social workers. Although it hasn’t been studied nor openly discussed, it seems that this unique course of professional development may have contributed to yet another tendency of Israeli therapists, i.e., integrative psychotherapy. Presently, there is a growing demand for CBT forms of therapy in public and in private practice.

The Introduction and Beginning of CT and CBT in Israel

CBT first appeared in Israel in the seventies of the twentieth century by a group of psychologists and social workers who studied in the USA and who brought back new ideas to be applied academically and clinically. During these years (1970s and 1980s), behavior therapy was met with resistance by the majority of clinicians, almost all of them psychodynamic-oriented professionals who expressed reservations regarding its practice, claiming it was too superficial, mechanistic, or outright dangerous. For example, Michael Rosenbaum, a psychologist who returned from the USA after specializing in child therapy, was invited to work in a psychiatric hospital where the head of the hospital argued that it was too dangerous to apply behavior therapy to children. During those days, the field was very conservative and traditional, and training and practice focused on dynamic therapy. At that time in university departments of psychology and social work all over Israel, some people started teaching behavior therapy (BT). However, it was not easy to teach behavior therapy while the field insisted on training in dynamic orientation. It then appeared as if the only settings where CBT [in those days actually behavior therapy (BT)] could be “tolerated” were settings with clients who suffered from severe psychopathology and with whom psychodynamic therapy was not possible. For example, a CBT pioneering project in Israel was a token economy program at a youth institute and another one with prisoners. Another important area for introduction and implementation of BT and CBT has been a joint collaboration of researchers and practitioners with the Mental Health Department of the IDF (Israeli Defense Force), which has developed numerous CBT-based treatments for chronic combat-related PTSD and shell shock among soldiers, veterans, and their families.

One such project – the Koach project – which gained publication was designed and implemented by the Mental Health Department of the IDF (Israel Defense Forces) Medical Corps as a treatment program for chronic PTSD veterans. The project was aimed to reduce the prevalence and severity of PTSD and to improve functioning in the military, the family, and the community. It was comprised of a 1-month residential stay at an army base, followed by mutual self-help groups in the veterans’ communities. The project combined CBT and group approaches into an integrated therapeutic program. The treatment approaches that were utilized included gradual exposure of soldiers to a return to military activities and group therapy of their wives aimed at increasing their function as a supportive resource in overcoming dysfunctional behavior (Solomon et al., 1992).

Along with the pioneering efforts of practicing BT and CT, the first academic courses in CBT were introduced in the 1970s at the Psychology Department of the Hebrew University of Jerusalem, at Tel Aviv University, and at Haifa University.

An important event for CBT in Israel was hosting the First World Congress of Behavior Therapy chaired by Michael Rosenbaum, which took place in Jerusalem in 1980. Its great success and attendance by many people from around the world (Ellis, Lazarus, Marks, and Eysenck were among keynote speakers) sparked the initiation of the Israel Association for Behavior Therapy’s active work and was a stimulant for the development of CBT in Israel.

Current Regulations Regarding Practicing Psychotherapy

In 2012, the Minister of Health issued the Mental Health Reform referred to as the National Health Insurance Order.

Professional registration and licensure to practice is carried out in accordance with each profession’s organizational requirement. For example, psychiatrists, psychologists, and art and speech therapist’s registration is done through the Ministry of Health and Ministry of Social Affairs and Social Services for social workers. Psychiatrists and psychologists receive their license from the Ministry of Health after an internship of several years and an examination. According to the guidelines of the Ministry of Health’s Clinical Licensing Board for psychologists and psychiatrists, all internship-training settings have to offer the interns the possibility of receiving supervision in CBT. Psychiatrists are examined on a CBT case as an obligatory part of their examinations. Several HMOs, in cooperation with the Hebrew University of Jerusalem, are developing CBT training programs for supervisors and licensed clinical psychologists who work for HMOs. The procedure in Schools of Social Work is slightly different as fieldwork is an integral part of the training and is part of the curriculum. CBT courses are part of the syllabus. At Tel Aviv University, specialization in social work with children includes CBT.

According to the new regulations of the Ministry of Health, both psychiatrists and psychologists are required to train in psychodynamic models and can choose between CBT and family therapy as a second choice during their internship. CBT is also included in the final examination. Unfortunately, these regulations are not easily applicable, notably among psychologists, due to a lack of CBT supervisors in the public services. An additional obstacle is related to “old establishment” psychologists’ criticism of CBT as being a technical and “superficial” mode of treatment. Nevertheless, since the Mental Health Reform demands shorter waiting lists for many more patients and therefore time-limited treatment, CBT will no doubt gain in strength as one of the few proven, efficacious, and efficient short-term therapies.

The Israeli Association of Cognitive Behavior Therapy (ITA)

There is one professional CBT association in Israel, ITA (Israeli Association for Behavioral and Cognitive Therapies). Since the history and development of CBT in Israel is closely linked to the establishment of the ITA, we will provide a short description of ITA and its activities.

ITA was formed in the 1970s by a group of psychologists and social workers who trained in the USA in behavior therapy and introduced the novel therapeutic model into Israel. The formal establishment of ITA as an NGO was in 1980 and very early ITA became a member of European Association of Behavioral and Cognitive Therapies (EABCT). Currently, ITA has 570 registered members, the majority of whom are psychologists, psychiatrists, and social workers who work in public and private clinical settings. ITA is constantly growing as manifested by the number of members being added each year. ITA’s aim is to encourage the use and expand the practice of CBT among professionals and potential clients. There are currently several CBT training programs in Israel. Most of these are approved by ITA, the formal association that also licenses members to become specialists and/or supervisors in CBT. At present, there is no law regulating psychotherapy as a profession, thus the licensing has no formal or juridical validity, but the general public recognizes ITA as the de facto licensing authority in the field of CBT.

ITA aims to be involved in community settings, in special populations as well outside Israel (e.g., training CBT therapists in Kosovo and Albania), and its members take an active part in international CBT conferences. ITA organizes conferences and workshops, seminars, and study days with well known, leading international and local experts, and its activities are very successful and well attended by therapists. For many years, ITA organizes an annual 3-day national CBT conference with a variety of workshops. Following the example of the European Association of Behavioral and Cognitive Therapies, the Israeli association added the term “cognitive” to its name.

As of 2018, all ITA’s registered dues-paying members have fulfilled the requirements for becoming CBT therapists, which are based on the “Minimum Training Standards” as published on the website of the EABCT. Most ITA members identify themselves as CBT therapists, as defined by the EABCT.

In 2015, ITA hosted the annual EACBT conference in Jerusalem entitled “CBT: A Road to Hope and Compassion for People in Conflict.” International and local leading CBT researchers and clinicians participated in the congress. In some ways, the first WCBT congress held in1980 and the EACBT congress held 35 years later, both of them held in Jerusalem, have come full circle.

ITA has its own website (www.itacbt.co.il) which provides a wealth of information on what is happening in the field of CBT in Israel and has a link to international CBT websites. A group forum and Facebook are active channels for discussions and provision of information to ITA’s members.

Training Opportunities for CBT in Israel

Importantly, academic training is a requirement for practicing therapy by all licensed mental health professions: psychiatrists, psychologists, and social workers. CBT and CBT training have become more popular in recent years. In the 1990s, the first 2-year training course in behavior therapy was established at the School of Social Work in Tel-Aviv University with trainees representing a variety of professions, including psychiatrists, social workers, psychologists, and nurses. For financial reasons, this program was stopped, but eventually, additional training programs were introduced.

Nowadays, courses in CBT are part of academic programs at all Israeli universities for students studying clinical psychology , social work, and counseling education. All graduate and postgraduate clinical psychology training programs include supervision on CBT in addition to supervision in traditional models. At present, 2-year postgraduate training programs that train professionals in CBT are offered privately and are accredited by ITA. An important step toward incorporating CBT as part of public services is the inclusion of CBT training programs that run under the auspices of several HMOs.

Over three decades, the training and practice of CBT has spread considerably and is clinically and empirically gaining strength while at the time adopting the new waves within CBT. In its early days, the most practiced mode of interventions were Beck’s cognitive therapy and Ellis’s REBT, the “first wave.” Throughout the years, what has become known as the “second” and “third wave” have become popular and attracted many CBT therapists who have completed the basic and advanced training. Most of them work with adults who suffer from anxiety disorders, OCD, PTSD, pain, stress, mourning, health problems, aggression, learning difficulties, etc. Some have also been trained in marital and family therapy.

What started with behavior therapy and followed with Beck’s and Meichenbaum’s CBT and Ellis’s REBT pioneering models (Dr. Ellis, Dr. Meichenbaum, and Dr. Judith Beck visited Israel and conducted workshops), presently ACT, DBT, SFT, schema therapy, mindfulness, and positive psychology, are also incorporated in the majority of CBT training programs. As CBT has gained more popularity, the need for textbooks and literature in Hebrew led to translating English textbooks into Hebrew, including texts about REBT, CT, BT, and ACT with children and adults. This trend has gradually grown into the publications by clinicians and researchers of texts in Hebrew of CBT-related topics so that there is now a large Hebrew library of CBT books and protocols (e.g., Marom et al., 2011, 2016; Mor et al., 2011). In 2019, the English prestigious IAPT model of D. Clarck and with his help, was initiated in the public service, directed by J. Huppert. Hopefully this will lead to a greater implementation of CBT in the public mental health service.

Who Delivers CBT?

Academic training is required for practicing therapy by the three licensed mental health professions who are officially recognized by the Ministry of Health: psychologists, social workers, and psychiatrists who may deliver CBT. Now that CBT is becoming professionally and publicly more recognized and accepted, training courses in CBT are now included in the syllabus of many academic faculties among which are medical schools, counselor education, and nursing. As the need for therapy is so great while the availability of academically trained professionals is limited, and because CBT is more open to training by other professions, Israel is witnessing a wave of CBT professionals from fields like criminology, education, dieticians, nurses, general practitioners, rabbis, speech therapists, and others. This is both a blessing and a curse: a blessing as many more potential clients can be helped without having to wait a long time before accessing therapy and a curse because often the theoretical and clinical background of these professionals is by far not enough to offer responsible CBT treatments.

CBT with Specific Clinical Populations in Israel

The Current Practice of CBT in Israel

As mentioned before, CBT is becoming more common in public mental health settings, and its practice is increasing while a similar trend already exists in private practice. Over the last few years, national and local institutions have substantially modified their attitude toward CBT by accepting CBT methods and sometimes preferring the short-term, structured, goal-directed options that they offer.

In many public and private settings, there is a CBT unit for the treatment of anxiety disorders, OCD, and PTSD. In a number of anxiety units, CBT is the treatment of choice with or without combined medication treatment. We will mention a few examples of such units. For example in Geha Mental Health Center (a well-known mental health center located in central Israel), there is a special unit for treating and research on social anxiety disorder. The unit was established in 2003 and is a leading one for this disorder. It practices CBT for SAD in both individual and group therapy. The center provides evidence-based treatment, training, and research studies carried out in affiliation with universities in Israel and abroad (Marom et al., 2009). Another example of combining practice and research in mental health outpatient clinics is located at Mirpaat Ramat Chen in which a special unit operates for treating PTSD where the majority of patients are Israeli army veterans. Other units of CBT outpatient clinics within hospitals operate throughout the country. Ichilov, a general hospital in central Israel with a multidisciplinary pain clinic that provides psychological CBT-based treatment, the anxiety clinic at Hadassah Hospital in Jerusalem, and a DBT clinic in Tzefat Government Hospital in northern Israel are also research-focused therapy. The security situation in Israel with its continuous and acute exposure to terror and war has triggered the developments of CBT interventions for reducing stress among civilian populations and work with individuals – soldiers and civilians who suffer from acute stress disorder and post-traumatic stress disorder. These interventions are especially tailored and widespread in Israel within military, public, and private mental health agencies and welfare settings. Two examples of centers that have developed services with CBT orientation for traumatized populations are the Community Stress Prevention Center (CSPC) (2020), a center for crisis and emergency services and increasing community resilience in northern Israel founded and headed by Dr. Mooly Lahad, whose Basic Ph model combines assessment and intervention tools based on CBT (Lahad et al., 2013). The CSPC is world renowned for its cross-cultural work with a variety of communities locally and abroad and the development of intervention programs following man-made and nature-made disasters. Another center is Metiv-Herzog Israel Center of Treatment of Psychotrauma founded and headed by Dr. Danny Brom to provide psychological help to adults and children following terrorist attacks who were exposed to psychological stress and trauma (Danieli et al., 2005; Metiv, n.d.). Both centers have extended their services beyond providing services to war- or terror-related psychological trauma to include bereavement and violence of all kinds while conducting research and training programs.

Another area where CBT has shown positive outcomes is work with children in the national schools and institutions. For example, the Ministry of Education trains educational counselors to work as behavior modification trainers and to help teachers utilize observation and reinforcement methods in class. This has become a special program for behavioral analysis in colleges for training teachers, and the profession is now part of the staff occupied in schools. Many special education institutions now include CBT programs that help change childrens’ behavior. Another development for children’s educational settings, still in its infancy, is a project designed to implement an innovative CBT milieu for children in boarding schools by creating a supportive community employing CBT and positive psychology orientations.

The most frequently applied CBT strategies are for individuals diagnosed with anxiety disorders, OCD, PTSD, and pain. A possible explanation is related to the collaboration between public mental health clinics affiliated with the academia by applying protocols to people affected with these symptoms and treatment that is evidence-based. To a lesser extent, mostly in private clinics, people affected by personality disorders are treated specifically by DBT, SFT, ACT, and REBT.

CBT Research in Israel

The outstanding and most developed field regarding CBT in Israel is that of research in the academic sphere. Cognitive psychology as an area of theory and research is prominent in most of the major universities. The development of theory and research on CBT in Israel can be traced back to the work on cognitive psychology by internationally leading psychologists, Daniel Kahneman and Amos Tversky, from the Department of Psychology at the Hebrew University. Another cornerstone in CBT research was laid by the late Aaron Antonovsky, who was a medical sociologist at the Ben Gurion University in Beer Sheba, who developed a cognitive theory with a core concept which he called the “sense of coherence” (Antonovsky, 1987). The sense of coherence refers to a set of personal beliefs that guide people’s coping with stress. A sense of coherence expresses the belief that life is comprehensible, manageable, and meaningful. The distinction proposed by Ronen and Rosenbaum (2010) between basic theory and applied theory indicates not only the different focus of each but also represents the progress in decreasing the gap between the “ivory tower” of cognitive psychology and its practice in combining clinical and empirical evidence-based studies.

Research on different aspects of CBT is currently conducted at universities and in some hospital-psychiatric departments affiliated with universities. CBT research studies includes a variety of subjects among which are theory and practice of OCD, ROCD, PTSD, grief therapy, GAD and social anxiety, ACT, schema therapy, mindfulness, self-efficacy and self-control, and cognitive grief therapy. The studies are carried by researchers and doctoral and MA students and can be categorized into three main areas:

  1. 1.

    Basic research that is aimed to develop theoretical models for explaining the contribution of cognitive components such as internal components of self-control, social support, self-efficacy, and hope and environmental components such as social and family support and meaningful figures to increase the individual’s ability to cope better

  2. 2.

    Control studies that compare CBT to medication, no treatment, or other mode of therapy for learning the effect of therapy on clients

  3. 3.

    Brain studies focusing on FMRI to better understand the way a disorder influences individual as well as in the way therapy can be seen in the brain simulations.

These studies are conducted with children, adolescents, adults, families, and elderly individuals and contribute to our understanding of the role of therapy in changing one’s ability to cope with stressors.

CBT with Special Populations Children and Older Populations

EFRAT and KOACH models for training teachers, adolescents, and children in emotional regulation are based on Beck’s cognitive therapy and Albert Ellis’s ABC model of emotional disturbance. These models are approved by the Ministry of Education and focuses on the centrality of cognitions and interpretations as a source of modulating stress. These appear in the form of course outlines adopted by different educational settings.

Ronen et al. (2013, 2014) and Shachar et al. (2016) developed a self-control model for reducing aggression and increasing well-being in children. The project has been adopted by the Ministry of Education and is now conducted all over Israel in elementary schools by trained educational counsellors.

In 2014 the National Council for Suicide Prevention of Suicide was established aimed at developing training and intervention programs. Mental health and school counselors are involved with at-risk populations: children, adolescents, young and old (70–80 years old), old-old adults (with the rising longevity, more people will live to ninety years and older, a group that attracts scientific attention in order to assist life span), and new immigrants (State of Israel, Ministry of Health, 2014). One of the programs, “the gatekeepers,” recruits volunteers who are key figures in the community (teachers, social welfare workers, parents, friends, nurses, caregivers in old-age nursing homes) and trains them to identify people at risk so they can provide first aid support and be liaison figures with social and mental health services. The training programs focused on short-term interventions such as CBT, problem-solving strategies, and positive psychology strategies (Ministry of Health Israel, 2017). One such intervention program, “Wellness and Mental Fitness Kit for Positive Aging,” for elderly people combines REBT and positive psychology (Bar-Tur & Malkinson, 2014; Malkinson & Bar-Tur, in press).

Concluding Remarks

In Israel, CBT has been developed to become a unique and independent domain of psychotherapy combining clinical practice and research to provide solutions to a variety of mental health problems. There is also an increasing demand for problem-solving focused, short-term psychotherapy such as CBT. The inclusion of CBT training as part of the curricula in medical and nursing faculties indicates the progress of CBT within the field of mental health, and yet it is also a challenge for CBT practitioners and ITA.

The age of personalized medicine with its focus on tailoring medical treatment to the individual characteristics of each patient will certainly challenge the field of psychotherapy. Notwithstanding the differences between the two (medicine relies on the person’s unique genetic), and psychotherapy (relies mostly on traditional understanding of human behavior), the former will effect psychotherapy. Individualized psychotherapy is therefore a challenge with additional areas to be considered including the development of the field of brain studies, virtual technologies, computerized therapy, and increasing numbers of individuals participating in clinical studies as collaborators in understanding human behavior (salutogenic and pathogenic). These trends raise the question: Should CBT retain its traditional framework of accrediting and certifying therapists or spread out the philosophy underlying CBT as a way of life by encouraging Low-Intensity Cognitive Behavior Therapy (LICBT) to be practiced by non-therapists. It is a stream in CBT done by moderators to make evidence-based simple psychological interventions more available for the community (Bennett-Levy et al., 2010).