Introduction

In health care, the most used and helpful definition of trust is ‘stress the optimistic acceptance of a vulnerable situation in which the truster believes the trustee will care for the truster’s interests’ (Hall et al., 2001, p. 615). According to Hall et al. (2002), trust is a multidimensional and complex concept that includes fidelity (putting the patient’s interests above all else), competence (both technical and communication-related), honesty (being truthful and avoiding falsehoods), confidentiality (protecting private information), and global trust (an overarching trust component that involves more subtle aspects of interpersonal communication). Patients’ trust might relate to the health care field in general, certain health care professionals, or health care organizations and institutions.

Trust is crucial in all aspects of medicine but particularly important in mental health. The relationship between mental health providers and patients is essential to the treatment of mental health problems, making trust a major factor in mental health care (Laugharne & Priebe, 2006). According to the European Mental Health Action Plan 2013–2020, mental health systems must acknowledge the historical legacy of communities’ mistrust and apprehension towards mental health services. When individuals with mental health issues and their families have confidence that their dignity, confidentiality, and safety will be protected, they are more likely to actively seek mental health services and maintain ongoing engagement with them (World Health Organization, 2015). Moreover, building trust in mental health services is essential to reducing stigma and discrimination towards mental illness. This objective requires efforts to earn the general public’s trust, patients, those who have used mental health services, those who have never used them, and their families (Gaebel et al., 2014).

In a review of the literature on trust in mental health, Gaebel et al. (2014) found multiple studies indicating a connection between using mental health services and trust in them. They concluded that having more trust in these services increases the likelihood of utilizing mental health services, as well as continuing treatment and actively engaging with the health care system as a whole. In addition, previous research has demonstrated the significance of trust in mental health professionals across diverse populations and settings. These studies indicate that trust in mental health professionals is associated with favorable health outcomes, such as seeking help for mental health issues, receiving effective treatment, consistent treatment, satisfaction, and working collaboratively with the treatment plan (Brown et al., 2009; Cromer et al., 2017; Fischer et al., 2016; Khatib & Farraj, 2014; Verhaeghe & Bracke, 2011; Wang et al, 2021).

However, much of the available research on trust has been conducted in the field of medicine. Conversely, there is limited research on trust in mental health, especially among ethnic minorities (Brown et al., 2009; Gaebel et al., 2014). This is surprising given that minorities generally feel uneasy about the mental health system and have less trust in mental health services and providers (Gaebel et al., 2014; Suite et al., 2007). Developing trust is particularly important within culturally diverse populations, as cultural and social values as well as structural barriers can shape individuals' perceptions of mental health, including trust (Xavier et al., 2023).

The scarcity of research on trust also applies to the Bedouin-Arab minority in southern Israel, which has unique social, cultural, and socioeconomic characteristics (Abu-Kaf, 2019). The Bedouin-Arab population in south Israel represents 27% of the inhabitants of the Negev, and 17% of the total Palestinian-Arab minority in Israel (Knesset Research and Information Center (KRIC), 2020). Around 67% of the Bedouin-Arabs live in planned villages and cities, while 102,000 individuals reside in unrecognized villages without basic infrastructure such as public transportation, waste disposal, running water, and electricity (Amara & Yiftachel, 2014; KRIC, 2020). In socioeconomic terms, Bedouin-Arab employees in Israel earn 26–45% less than the national average and have twice the unemployment rate of the general population. Only 48.1% of Bedouin-Arab students graduate high school with a matriculation certificate (Eyal & Tirosh, 2018; KRIC, 2020). All Bedouin-Arabs in Israel are Muslims and share similar socio-cultural characteristics as other Palestinian-Arab citizens. They are known for their traditional, collectivist society, which maintains close social relationships and mutual support in families and communities (Abu-Kaf, 2019).

The limited research on mental health in Bedouin society suggests high levels of psychological distress (Abu-Kaf, 2019). According to Abu-Kaf (2019), Bedouin students revealed higher rates of depressive and somatic symptoms than Jewish-Israeli students in a recent study. Also, a recent study found that Bedouin women experience greater psychological distress than Arab and Jewish women from other regions of Israel (Khatib et al., 2021). The available studies suggest that Bedouin-Arabs underutilize mental health services (Al-Krenawi & Graham, 1999, 2000, 2011). Bedouins tend to only seek help from mental health services as a last recourse, after seeking help from family and friends, their family doctor, and traditional healers (Al-Krenawi & Graham, 1999). Unfortunately, Bedouin society has a significant shortage of mental health professionals. Official reports regarding the number of Bedouin professionals are lacking, and mental health services within Bedouin society have not received significant attention from scholars or government authorities. However, a recent report by the State Comptroller indicated that only two Bedouin-Arab psychologists are currently available (Al-Krenawi, 2019; State Comptroller of Israel, 2020). While the exact number of mental health professionals from other specialties, like psychiatrists or psychotherapists, remains unknown, the reported number of psychologists may serve as an indicator of a broader shortage of Bedouins professionals in the field. In addition, according to Al-Krenawi (2019), in the Bedouin culture, like other Arab cultures, mental illness can be viewed as a punishment from God or attributed to supernatural sources, while biomedical model is often rejected. This leads to stigmatization and a taboo surrounding mental health, creating barriers to seeking help. Additional research highlights various barriers the Bedouin-Arabs face in Israel when accessing mental health services. These challenges encompass a lack of mental health literacy, which includes insufficient knowledge about mental health professionals, available services, and the causes and risk factors associated with mental health issues. Additionally, entrenched traditional attitudes, including a preference for informal treatment, skepticism towards mental health treatment, and the perception of mental well-being as a privilege, further impede their utilization of mental health resources (Abo-Rass et al., 2024).

Building upon the literature presented, this study aims to explore trust in mental health professionals and services among the Bedouin-Arab minority in Israel. The study uses Hall et al. (2002) definition and a qualitative approach to gain a deep understanding of trust issues in mental health.

Method

Participants

The study involved 25 Bedouin-Arab Israeli citizens aged over 18 living in Bedouin villages and towns, which is considered adequate for achieving data saturation in qualitative research (Guest et al., 2006). Fifteen individuals were female (60%), and 15 participants were married (60%). On average, the participants in the study were 34.08 years old (SD = 10.5; Range 22–58). Additionally, they had 13.72 years of formal education (SD = 3.31; Range of 0 to 17).

Procedure

The Ethics Committee of (Blind to reviewers) approved the research protocol. The data collection and analysis followed the grounded theory methodology (Charmaz, 2006; Sbaraini et al., 2011).

The first author, along with two research assistants (both Master’s students in welfare and health studies), posted an ad on social media to recruit potential participants, which explained the study’s goals and methods. As a result, several participants expressed their interest and introduced us to other potential participants they knew and willingly agreed to participate (snowball technique). Before conducting the interviews, the participants received another explanation about the study and signed an informed consent form. The interviews were done in three rounds using the grounded theory method. Some participants were re-contacted to clarify ideas, and some were interviewed twice, allowing theme refinement (Sbaraini et al., 2011). All interviews were conducted in Arabic by the first author and the two research assistants, all of whom are experienced in qualitative interviews. The interviews lasted around 50 min and were recorded and transcribed. To ensure confidentiality, all identifying information was removed from transcripts.

Interview Guide

Semi-structured in-depth interviews were conducted with the participants to gather insights into their experiences and perspectives on trust in mental health professionals and services. The interview began with general questions about the participants’ background and knowledge of mental health. This was followed by more targeted questions focusing on trust in mental health professionals, as per the definition provided by Hall et al. (2002). For example, ‘To what degree do you feel trust/distrust in mental health professionals such as psychologists, psychiatrists, and social workers?’; ‘Can you please give a specific example of an interaction you had or heard that shaped/impacted your degree of trust/distrust?’; ‘Do you think the Bedouin society trusts/distrusts mental health professionals?’; and ‘How is this distrust/trust expressed?’ Since this study followed the grounded theory method, the interview guide was adjusted after each analysis stage, and questions were added to clarify and expand some of the ideas raised by the participants.

Data Analysis

We analyzed the data using the three stages of Charmaz’s (2006) grounded theory approach with ATLAS.ti ver. 9. First, the study researchers performed independent initial coding by engaging in open coding, carefully reading, and analyzing each interview’s content to identify the main ideas and underlying meanings. The research team includes three mental health researchers: a Bedouin-Arab, a Palestinian-Arab, and a researcher with extensive knowledge of the research population and Israeli context. This diverse team ensures a culturally sensitive examination of the data. Second, focused coding was conducted to pursue a selected set of most prevalent or essential codes throughout the entire study dataset. Finally, we refined our final categories and arranged them into themes, discussing categories and discrepancies until a consensus was reached. The final codebook, including themes and sub-themes, was developed in this stage. The first author then continued coding the interviews and selected relevant quotes for the results section (Miles et al., 2013).

Results

The analysis of the interviews revealed three main themes regarding distrust. This lack of trust was directed exclusively towards Bedouin mental health professionals rather than towards mental health professionals in general. The first theme discusses how distrust is reflected, the second delves into the socio-cultural context, and contributing factors that lead to distrust, and the third explores the consequences of the lack of trust. Table 1 summarizes the study’s themes and sub-themes.

Table 1 The study's main themes and sub-themes
Full size table

Theme 1: Concerns Around Confidentiality Leading to Distrust in Bedouin Professionals and Local Services

Confidentiality: The Key Distrust Issue Towards Bedouin Mental Health Professionals

The primary concern related to trust in Bedouin therapists centered confidentiality.

As reported by most participants, there exists a general perception that mental health professionals from the Bedouin society may sometimes face challenges in establishing trustworthiness. This is because they are believed to be incapable of keeping their patients' information confidential and private. The participants were also concerned that Bedouin mental health therapists share personal details about their patients with others, including colleagues, families, and friends.

"I don't feel comfortable sharing personal details about my life with Bedouin therapists in mental health services. I do not trust the therapists themselves who provide the service. I have heard that conversations are not kept private, and that information is shared in the hallway between therapists, compromising patient confidentiality. As soon as you enter and leave the service, Bedouin therapists already pass on your information" (Participant 4, female, age 30)

"We distrust mental therapists from the Bedouin society because they share with others about their patients; they tell X came to me for treatment and talk about his problems and the treatment he was given; there is a lack of confidentiality and a lack of protection of patients' privacy" (Participant 21, male, age 24)

There seems to be a prevailing lack of trust related to confidentiality in Bedouin therapists among members of the Bedouin society.

"Maybe only 2% of the Bedouin society trusts Bedouin mental health professionals. Can you trust them [Bedouin professionals] to keep your confidentiality and privacy? I can't, not 100%" (Participant 12, female, age 23)

In addition, the participants asserted that this perception of distrust in Bedouin professionals exists as a general perception towards all mental health professionals, regardless of their specific field of expertise, and regardless of whether individuals have personally experienced it or heard about it directly from someone else. That is why they also often discussed distrust towards other medical doctors in the interviews. The participants believe that changing this perception is a challenging task. They feel that professionals are often under scrutiny and must constantly prove their intention to protect the privacy of their patients.

"There is a lack of trust, but I can't say that I have experienced it or heard of specific cases from people, but there is talk of a lack of trust" (Participant 7, male, age 54)

"Generally, we examine the Bedouin therapists; they are constantly tested for trust. I won't go to them for treatment, and that's it; it is crucial to verify their ability to maintain confidentiality before undergoing any treatment. I would not proceed without this confirmation" (Participant 22, female, age 32)

Distrust in Public and Community Mental Health Services Within Bedouin Localities

Over half of the participants expressed distrust towards state-funded mental health institutions and services located within the Bedouin localities. It is important to mention that the participants lacked trust specifically in public or free mental health services provided under the universal health care bill, like those offered by HMOs or welfare services provided by local authorities. They believed that private and out-of-pocket services were better as they would offer a greater sense of trust that their confidentiality would be protected.

“Many individuals hesitate to seek mental health care through HMOs or local authorities due to confidentiality concerns. People are willing to pay more for private treatment to avoid the possibility of leaks in these services. People fear that if they seek public services, there will be leaked information about them and violate confidentiality” (Participant 13)

“I don’t trust specifically professionals who work in HMOs” (Participant 4, female, age 30)

Greater Trust in Mental Health Professionals who are Jewish or Non-Bedouin Arab

Many of the study participants have expressed greater trust in mental health professionals who are either Jewish or non-Bedouin Arab, in contrast to Bedouin professionals. Notably, this trust primarily revolves around confidentiality and extends to mental health services not located in the Bedouin community, with participants expressing greater confidence in these services.

"I trust Jewish professionals more than Arab professionals due to their ability to maintain confidentiality" (Participant 9, male, age 35)

"I think people don't trust mental health services, especially those located in Bedouin society; maybe there is more trust in mental health services located in Jewish society" (Participant 10, female, age 35)

Theme 2: Factors Underlying Confidentiality Distrust in Bedouin Mental Health Professionals

The Perception of Bedouin Professionals as Unprofessional

Most participants viewed Bedouin professionals negatively, perceiving them as unprofessional, contributing to their distrust of Bedouin therapists. They attribute the therapists’ lack of professionalism to two main factors: the Arab academic institutions outside of Israel, where most of them acquired their professional education, and their perceived negative style and attitude. Moreover, the mental health services available in the Bedouin community are generally regarded as unprofessional and of lower quality.

"Mental health therapists in the Bedouin society are not professional, there are certainly exceptions, but in general, they are not at a sufficient level of professionalism that allows them to maintain the confidentiality of their patients. I think we don't trust them because of their lack of professionalism and because of the low quality of mental health services provided" (Participant 19, male, age 35)

"The Bedouin society tends to choose non-Bedouin therapists due to their attitude and style. Unfortunately, the therapists' style is not good here in the South. What sets them apart is that they have a certificate and some knowledge. The question is how they provide this knowledge and treatment to patients. Most of them also finish psychology studies, for example, in non-Israeli universities, when in general, in high school, they were in unrelated majors such as Arabic or environmental studies. Unfortunately, not in a professional way, and therefore the Bedouin society does not trust them" (Participant 15, female, age 24)

The participants observed that in Bedouin society, services provided by non-Bedouin professionals, particularly Jewish-Israeli therapists, are generally considered more efficacious, leading to greater trust in them.

"According to the perception of the Bedouin society, Jewish therapists are always more competent, and therefore they are trusted and preferred to turn to them. The Jewish therapists focus on the person suffering from mental distress, they have skills, and I feel that all their services are different from our services" (Participant 10, female, age 35)

The Social Structure of Bedouin Society: A Close-Knit Community

Most participants described Bedouin society as a close community, where people have strong relationships with each other, and everyone knows each other. According to the participants’ description, people in the community often turn to professionals for information about their relatives, either out of concern or curiosity. For example, a man who wants to marry a woman may first check her health and mental background. This widespread and socially acceptable behavior in society jeopardizes the privacy of community members and increases the hesitancy to trust Bedouin therapists. In addition, social gatherings are common in Bedouin society, where people discuss various topics, including work. Bedouin therapists are also a part of these gatherings, sharing about their work as mental health professionals. However, even if therapists speak in general terms and avoid identifying details, the close-knit nature of the community makes it easy to identify them, which can lead to distrust issues.

"Our society has strong connections between individuals, including close family ties, which can lead to conflicts. Unlike in Jewish society where personal lives are not interfered with, people in our society tend to inquire about each other, causing some individuals to avoid seeking treatment to avoid scrutiny and questions" (Participant 13, female, age 37)

"Girls don't seek mental health care because they fear that it will show up in their medical file later and it will be difficult for them to get married. Because people are snooping. I don't want someone rejecting me for rummaging through my file and finding out I was in therapy. For example, my doctor, who is of Russian origin, called me once and told me that someone I know contacted him and asked him for my private health information" (Participant 4, female, age 30)

"Bedouin mental health professionals can tell their brothers or friends at social gatherings that they usually talk about work, and they can be drawn into it and talk about their patients. They [Bedouin professionals] may not say names and only talk about the cases and stories, but people can easily identify who it is because everyone knows everyone. Bedouin society is afraid of these situations" (Participant 24, male, age 48)

Fear of Stigmatization and Responsibility for the Family’s Reputation

Most participants distrusted sharing their personal and familial concerns with mental health professionals in general. However, they found it even more difficult to discuss these matters with Bedouin therapists. The participants cited two primary reasons: First, a social stigma is attached to seeking mental health care in Bedouin society. The participants claim they do not risk turning to a Bedouin therapist; they fear that if their mental health problems become public knowledge, they will suffer from societal discrimination that may negatively affect their personal, social, and professional lives. Second, participants believe that Bedouin individuals represent their immediate and extended families and are responsible for upholding their family's good name and social standing. Consequently, participants fear disclosing personal and mental health issues could harm them and their families' reputations.

"If we want to see a therapist, we don't want anyone to know, like family or friends. Because there is a stigma that those who seek mental health care are crazy. We want it to stay between the therapist and us" (Participant 17, female, age 36)

"It's like going to a Bedouin therapist and talking about personal things would shame me because, in the end, it's my family I'm talking about. I don't believe that mental therapists and a lot like me keep secrets. And this is especially critical in our Bedouin society because we are a society made up of extended families; the dignity of a person and the pride of his family depend on each other. So if the Bedouin therapist shares your problems with others, it hurts your whole family. And in general, when you communicate with a Bedouin therapist about your family problems, for example, they will think that the whole family is problematic, and that's how you hurt your family's name. Sometimes also, out of a high ego, we don't want to turn to a Bedouin therapist from another family, especially those that have competed with our family, because we don't want to provide them with information and confirm to them that we are not good" (Participant 18, male, age 24)

Power Dynamics Perceptions and Cultural Values

Over half of the participants explained that power dynamics exist in Bedouin society. These power dynamics can result in mental health professionals sharing confidential information. Participants believe that religious figures or Well-known/respectful leaders can request information about individuals from mental health professionals. Due to this perception, mental health professionals feel obligated to share the requested information. Additionally, one participant mentioned that even official institutions violate confidentiality due to power dynamic.

In addition, participants have expressed their concern that certain cultural values clash with the need to maintain patient confidentiality. They feel that these cultural codes often take precedence, leading to a lack of trust in Bedouin mental health professionals. For instance, according to the participants, in Bedouin society, it is customary for a son who is a mental health professional to disclose patient information if asked by a very close relative, such as a father or grandfather. This is seen as a sign of respect towards elders, and failure to comply is viewed as a sign of disrespect.

"Sometimes the Sheikh [religious leader] has power over the institutions and the police, and you will always find that he has all the health information. Actually, it is possible that even official institutions will provide information about people to those sheiks" (Participant 13, female, age 37)

"I believe some Bedouin therapists may share sensitive information about their patients with parents and grandparents upon request. Of course, some therapists would not do that, but we grow up in a certain world of values that we follow, and it can be challenging to overcome, even as professionals" (Participant 19, male, age 35)

Theme 3: The Consequences of Distrust

Not Seeking Mental Health Help

Distrust in Bedouin mental health therapists and institutions was found to be a barrier to the utilization of mental health services in Bedouin society. The participants claim that the lack of trust prevents them from seeking services from those mental treatment centers available in their places of residence.

"The Bedouin therapist should maintain confidentiality and not share about his patient. The patient should feel trust towards the therapist, but unfortunately, many therapists talk about their patients and do not keep confidentiality. This is what makes people not seek mental health services" (Participants 7, male, age 54)

Preference for Mental Health Professionals who are Not Bedouins, Raising Challenges with Cultural Differences and Language Barriers

According to most participants, they tend to avoid seeking help from Bedouin mental health therapists due to distrust. Instead, they opt to go to non-Bedouin therapists, including non-Bedouin Arab or Jewish therapists and even refer others to them. Participants believe a mental health therapist not associated with their community is less likely to violate confidentiality. This is due to the same reasons mentioned in theme 2, including non-Bedouin therapists having no personal connection or shared social circles with the Bedouin patient, reducing the risk of information being exposed.

"A Bedouin would prefer to contact an Arab professional from the north rather than professionals from the Negev. This is a very important factor. He will say that they live far away and don't know me, and the exposure is less. That is, his interest will not be revealed publicly. That's why I prefer to contact therapists from the North rather than from my society" (Participant 8, male, age 25)

In this context, the participants mentioned that turning to a non-Bedouin mental health therapist, particularly a Jewish-Israeli, is challenging for them due to cultural differences and language barriers, as the Jewish therapist often does not speak Arabic and may not understand the cultural nuances.

"The issue of trust in a Bedouin mental therapist prevents people from turning to a Bedouin therapist. On the other hand, if you turn to a Jewish therapist, he may not understand you. This causes a dilemma. You may feel comfortable telling a Jewish therapist everything you want and trust him, but he won't understand you or understand exactly what you mean. While the Bedouin therapists will understand you one hundred percent, but you can't trust them, especially if you know them" (Participant 1, female, age 44)

Discussion

In this study, we explored trust in mental health professionals among Bedouin-Arabs in southern Israel, using a qualitative methodology to understand this important aspect of mental health that has been linked to mental health outcomes and behaviors (Brown et al., 2009; Cromer et al., 2017; Fischer et al., 2016; Khatib & Farraj, 2014; Verhaeghe & Bracke, 2011; Wang et al, 2021).

The study's findings reveal a pervasive distrust among Bedouin-Arabs of mental health professionals, particularly those from within their society and the services offered in their communities. Participants expressed concern mainly about confidentiality and privacy of their personal information, which was the core issue underlying distrust in Bedouin mental health professionals. The lack of trust was revealed towards all Bedouin mental health professionals regardless of their specific profession. It is likely that due to low mental health literacy, members of the Bedouin society may lack knowledge about mental health professionals and have difficulty differentiating between them and the treatments they provide (Abo-Rass et al., 2024).

This lack of trust in Bedouin mental health professionals is consistent with the previous research, showing a general distrust in mental health providers and services among ethnic minorities (Brown et al., 2009; Gaebel et al., 2014; Suite et al., 2007). However, unlike other minorities who distrust professionals from majority groups, the members of the Bedouin minority do not trust professionals from their group, specifically for fear of their confidentiality, and it does not necessarily extend to other aspects of trust, such as honesty or loyalty (Hall et al., 2001).

Several factors may contribute to this confidentiality distrust, but interestingly, these factors are not necessarily related to the professionals themselves or based on direct experiences with them. In the case of the Bedouin society, the findings suggest that their close-knit social and cultural structures may lead to a lack of trust and apprehension regarding privacy violations by professionals. This emphasizes the significance of considering individuals’ cultural and social contexts when investigating mental health services. This perspective acknowledges the interdependence of psychosocial elements of mental health with the values and norms diverse communities uphold (Alegria et al., 2010; Lacy et al., 2021). Furthermore, our findings suggest that the Bedouin society contends not only with structural discrimination, including a shortage of mental health services and professionals (Al-Krenawi, 2019; State Comptroller of Israel, 2020), but also faces challenges related to the cultural compatibility of the services provided. This is concerning, as the literature indicates that mental health services and interventions that lack cultural adaptation can impede individuals from seeking mental health help (Memon et al., 2016; Rathod et al., 2018).

Our study further demonstrates how stigma exacerbates the sense of distrust concerning confidentiality, within the Bedouin society. This distrust is rooted in the fear of breaching privacy, as individuals are primarily concerned about the potential consequences of stigma when information about their mental health issues and treatment becomes known to others. In a recent study among the general Palestinian-Arab minority in Israel, the primary determinants of mental health service use were not found to be stigma-related barriers, but rather attitudinal barriers (Abo-Rass et al., 2022). Based on the findings of this study, it is possible to gain insights into the role of stigma in influencing other mental health-related variables, such as trust, as well as its potential indirect impact on health behaviors and the utilization of mental health services.

Another related factor that has been found is the perception of unprofessionalism of Bedouin professionals. Previous studies have shown that when mental health professionals are perceived as unprofessional, it can harm the level of trust individuals place in them (Gaebel et al., 2014; Laugharne et al., 2012). The present study suggests that Bedouin society is skeptical of Bedouin professionals and their ability to maintain confidentiality and uphold professionalism in the face of cultural and social pressures. This perception relies on society's belief that some cultural values such as respect for elders hold more significance than others. Additionally, many Bedouin professionals received their formal education and mental health training from Arab universities outside of Israel, which Bedouin society views as less valued (KRIC, 2014). Based on our research, the common perception of Bedouin society is often based on hearsay and not on direct personal experience or knowledge of someone within the community. Due to the lack of accurate data, it is possible that minority groups, including Bedouins, even in the context of mental health and the perception of trust in professionals, may be affected by self-stigma processes when they internalize negative perceptions from the majority towards them and their professionals and institutions (Cokley, 2002; Jones, 2000). Furthermore, the structural barriers to care include an insufficient number of Bedouin therapists available, given the mental health needs of the Bedouin-Arabs (State Comptroller of Israel, 2020). This puts a heavy burden on them, which could directly impact their work quality and overall work satisfaction and efficacy. It is equally important to acknowledge that these professionals require support and guidance when navigating cultural complexities. Unfortunately, they often confront these challenges in isolation, lacking access to well-qualified mentors who can offer culturally tailored strategies.

Another crucial finding is that the analysis indicates a lack of trust not only towards Bedouin mental health professionals but also extends to distrust in public and community mental health services within Bedouin localities. Interestingly, there appears to be greater trust in private services. It is worth noting that the state provides public mental health services free of charge to all citizens under the universal health care law in Israel. This finding can be contextualized within the broader attitudes of Palestinian citizens of Israel, including Bedouins in the south, towards official state institutions, encompassing both general and mental health services, which are often met with suspicion (Al-Krenawi, 2019). Additionally, instrumental barriers such as the previously mentioned workload, specifically in community services compared to private ones, and the larger teams, which heighten the likelihood of interactions between professionals in these services, may also contribute to the participant's perception of an increased risk of breaking confidentiality.

Finally, similar to previous studies that found a correlation between lower trust in professionals and low utilization of mental health services (Cromer et al., 2017; Fischer et al., 2016; Gaebel et al., 2014), we also observed a similar trend within the Bedouin society. Furthermore, the consequences of this lack of trust sometime prompt individuals to prefer therapists from another culture, which makes them concerned about potential misunderstandings. That means that even within discriminated minorities with limited access to services, various psychosocial barriers, in addition to structural barriers, can impede access to mental health treatment. This stresses the importance of increasing trust in professionals to encourage seeking mental health help. Moreover, our research suggests the importance of considering potential difficulties and cultural differences when exploring alternative options. However, the findings raise a crucial issue about rendering mental health care in collective, traditional, and closed communities. It is necessary to reconsider the approach, method, and location of mental health care provision in these communities. It is essential to make significant and substantial cultural modifications to existing models of mental health care, which are currently more geared towards Western and individualistic societies.

Limitations

There are limitations in our current study that we need to address. Most of our participants are from recognized villages and towns. Future studies should also include individuals from unrecognized villages that are characterized by a more traditional lifestyle and additional difficulties, affecting views on mental health-related matters. Moreover, the individuals in the sample have a higher formal education level than the overall education average in Bedouin society, which might be because of the social media part of the recruitment process; future studies should expand the recruitment methods. However, this could potentially influence the results as educated individuals may have varying perceptions and experiences compared to those with lower education levels. They may also be more impacted by the societal changes that Bedouin society is undergoing, which could influence their viewpoints on trust in mental health professionals. Finally, our sample comprises mainly young individuals, as there were no participants above the age of 60. Although, representative of the median age of Bedouin society, this limitation restricts the applicability of our findings to the older age group. While the elderly constitutes a small portion of the population, their distinct needs, particularly given the shifts in their social standing, emphasize the importance of dedicating increased consideration to this age group.

Implications

To our knowledge, this is the first study to explore issues related to trust among Bedouin-Arabs in Israel in the context of mental health services. The study findings and conclusions broaden our understanding of this topic, particularly among marginalized and minority groups. Interventions aimed to increase mental health service use among this group or similar groups can be informed by this study and focus, among other things, on increasing trust in mental health professionals, tackling confidentiality concerns and correcting misconceptions on the subject, and providing information on adapted mental health services. Based on this study's findings, we can suggest various measures for implementation, both in terms of research and practicality. First, it might be beneficial to interview Bedouin-Arabs professionals to understand their experiences and coping mechanisms and gather their recommendations for building trust. A replication study with a broader and more representative sample of the public is strongly recommended. Another study that quantitatively examines distrust and its relationship with various socio-demographic variables is also essential. Moreover, a comparative analysis between the current study's population and other non-Bedouin Arab groups is crucial for gaining deeper insights into the cultural factors influencing this phenomenon. Clinical implications include the need to raise awareness among professionals about the need for more trust towards them and ways to address it. Bedouin professionals should receive proper training on how to increase trust with their patients, as well as how to ensure patient privacy. Policy implications include the need to educate the public about the ethical codes that mental health professionals follow, such as protecting patients' confidentiality and privacy. Efforts should be made to enhance the reputation of Bedouin professionals through conferences, campaigns, and personal interactions with therapists from society. Finally, regarding policy, the Israeli government should collaborate with universities to offer funding and create mechanisms to increase the representation of Bedouin in mental health care training. This would lead to an increase in the number of mental health professionals graduating in Israel, presumably the quality of the training provided. The curriculum for these programs should also prioritize cultural competence in mental health care across various societies in Israel. Additionally, the Ministry of Health should systematically collect information about mental health services in Bedouin society to continuously evaluate the quality of mental health services. These plans would include objective indicators and report to the public to address any misconceptions and lack of knowledge.