Israel's clinical psychologists fear they will be replaced by cheaper workers
Following a recently passed mental health reform, psychologists worry that cost-conscious health maintenance organizations will try to reduce costs by employing low-cost health workers in lieu of residents.
For more than three months I have been waiting for the end of a simple bureaucratic procedure, one which the Health Ministry says should take no more than two weeks. I am supposed to be registered on the roster of approved psychologists. During these 10 weeks I could have moved ahead and started my work as a resident; but this whole period has been wasted. Even though my master's degree in clinical psychology should suffice, I have been asked to furnish all sorts of documents and certificates from the recent and distant past, and all of these, of course, must be original documents, not copies. One clerk even whispered to me that were I to supply a document saying that I have no criminal record, that would expedite the process. I've done everything, but I'm still waiting.
This account tells only part of the story of what it's like to become a clinical psychologist in Israel. Becoming listed on the official roster of psychologists is neither the start nor the finish of the exhausting journey.
First, the would-be professional has to be accepted for undergraduate study, then complete his studies with high grades; then there is a demanding classification exam ("Matam" ), along with the requirement of completing a master's degree in the field with distinction. The graduate work includes a year or two of training with experienced professionals in the field. After completion of a master's, the graduate can call him or herself a "psychologist," at least the moment registration in the professional roster is completed.
Then comes residence work, usually a four-year procedure under half-time terms of employment. The final step is a professional licensing exam.
The Health Ministry is responsible for monitoring the aspiring psychologists' training. The ministry issues licenses and distributes grants that fund the pitiful salaries earned by residents (usually less than NIS 2,500 a month ).
The hundreds of residents constitute a large portion, perhaps half, of the psychologists engaged in public service. Public services include a network of government clinics, and under the recently passed mental health reform, these clinics will be placed under the responsibility of the country's health maintenance organizations by 2015. After the Knesset refused for several years to authorize the mental health care reform, the government several months ago issued an order to approve it.
Health Ministry officials claim the reform, which puts the clinics (and the residents who work in them ) under the responsibility of the HMOs, will improve service to patients. Yet the psychologists are worried that the cost-conscious HMOs will try to reduce their expenses by employing low-cost health workers in lieu of residents. Residents who remain and work in the HMOs, the psychologists believe, will not receive top level training - the HMOs have little interest in investing in the residents' careers, the psychologists explain.
It appears that the psychologists' fears concerning the quality of residents training, and the possible of non-employment of the residents, have foundation. Haaretz has learned that under the agreement signed by the HMOs, the Health and Finance ministries, the HMOs incur no obligation to finance the training of residents.
Also, the HMOs are not committed to employing a minimum number of residents in the clinics. Health and social service workers who might be hired instead of aspiring clinical psychologists include nurses, social workers and occupational therapists.
Hannah Strum-Cohen, a senior clinical psychologist and a key figure in the psychologists and social workers forum, does not believe that the mental health reform promises a rosy future for aspiring professionals.
"The Health Ministry is moving ahead with this reform in secrecy," she says. "Were this a good reform, the agreement between the state and the HMOs would be open and public," she says.
Strum-Cohen, who has been involved in discussions and debates about mental health reform for over 10 years, states: "I have long said that there has to be an explicit clause [in the reform] for budget allocations to train residents. Theoretical studies do not train anyone to be a caregiver. In order to be a caregiver, a candidate needs to undergo an intensive training process. If no such training is given, then the residents essentially turn into slaves, a low-cost labor force which is exploited throughout years of residency."
Strum-Cohen expressed concern that lower-level health workers will be employed instead of clinical psychologist residents; these are low salary workers who will be given "quickie training," she says, to provide various health services.
Psychiatrist Dr. Gadi Lubin, head of the Health Ministry’s mental health department, sounded quite calm when I presented him with the apprehensions that arose during my talks with psychologists.
When asked about the amount of psychologists that will be able to work in HMO clinics in the future, Lubin responded that the Health Ministry “is not meant to determine the composition of HMO staff,” though he is estimates the rate will be the same as that of psychiatrists – roughly a third.
At the same time, according to Lubin, the HMOs will keep psychologists at the “core” of their clinics, as there are many of them in Israel. “There are thousands of psychologists in Israel, many more than psychiatrists,” he pointed out. Lubin also noted that there are other reasons to employ psychologists – they aren’t necessarily more expensive than other therapists, and, residents have stipends that supplement their salaries.
When I asked to see a copy of the agreement between the state and the HMOs he agreed at first – but then decided there was no reason to see it, as many of the clauses are “no longer relevant,” as the agreement has undergone many changes during the past few months.
I expressed my amazement at the fact that the government has already approved the reforms even though both sides are still negotiating the details, and Lubin responded that while there is still some room for maneuvering – the agreement is not completely unfinished. He promised that “within a few weeks, many of the issues you see as vague will be cleared up.”
Lubin also pointed out that the huge sums the government has been spending on the field of mental health – more than double the amount spent on clinical treatments, he said – will lead to an improvement in the status of therapists, and waves of new psychologists being recruited into clinics.
In response to the delay in registration in the psychologist’s roster, the Health Ministry apologized, and claimed that it was due in part to “human errors.”
Could psychologists reservations over the coming reforms spark a real protest? Another clinical psychologist, who recently finished his residency and is working in the public sector, expressed his doubts. “At the moment, we are in a fog of war, and no one knows what we’re facing,” he said.
“Also, the last active steps taken by the psychologist community as whole took place about 15 years ago. This is a community that goes about its business in the clinic, internally, and unfortunately, is not used to taking action to change the external reality. It pains me to say it, but from my experience with the psychologist community, not much will happen.”