Is the Health Ministry Downgrading Psychology?

Ministry officials, HMOs apparently in two minds over reducing the number of clinical psychologists at public health clinics

The Health Ministry's chief psychologist, Yemima Goldberg, who is responsible for the licensing of psychologists, has rejected criticism in a November 6 op-ed in Haaretz by Rafael Yonatan Leus, under the headline “Say goodbye to clinical psychology.”

In his article, Leus, a resident in clinical psychology and a doctoral student in the Hebrew University of Jerusalem’s psychology department, warned against removing psychologists from public health clinics as part of a reform of mental health services. The move, Leus, argued, would spell the death of the profession here.

Leus wrote that according to a recently disclosed document that outlines personnel requirements at community clinics, “psychologists won’t be included in the multidisciplinary teams responsible for mental health, and they will also be dropped from the list of professionals authorized to run mental health clinics.”

Leus also warned of severe harm to the clinical psychology specialty following the publication of another “no less dramatic document” recommending a change in the nature of the clinical psychology specialization, which he said reflects a “reductionist, piecemeal approach to the human mind.”

Goldberg responded to the opinion piece in an emailed newsletter published by the Israel Psychological Association in which she acknowledged that the article had prompted a major reaction, but added that “there is no decision or trend involving removal of psychologists from the clinics.”

“In addition,” Goldberg wrote, “in preparation for the reform, 21 new mental health clinics have been opened so far, and 28 clinical psychologists have been recruited for them. In addition to them, there are the 13 new Clalit health maintenance organization clinics. An expansion of clinics is planned, along with an increase in the number of psychologists. There is no doubt that the integration of the psychologists in these clinics constitutes [an integral] part of their existence.”

And contrary to what Leus wrote in Haaretz, Goldberg said, psychologists indeed will be able to serve as community health clinic directors once the reform is in place. That, she said, is stated explicitly in the Health Ministry’s official document on the subject. Goldberg also rejected Leus’ claim that the reform would do damage to those doing psychology residencies. In fact, she claimed, the budget for scholarships to fund residents’ salaries was increased by 10 million shekels for 2014 and 2015.

When it comes to the changes in the residency procedures that Leus warned against, Goldberg hinted that perhaps the proposed steps are not final. “The additional document that was mentioned in the column … will be discussed among the professionals [involved],” she wrote, adding that Health Ministry Director General Roni Gamzu also completely rejected the arguments in Leus’ article.

“It is very important,” Goldberg wrote, in conciliatory tones, “for the field to be aware of what is happening, and that it questions things that are not sufficiently clear and does not desist until it receives suitable responses. We prefer to have the field respond and act rather than being passive.”

For his part, however, Leus is insisting that the major point that he sought to make in his article remains valid. That is the lack of a commitment to staffing of psychologists and residency training of psychologists at community clinics once the reform is in place.

“Unlike psychiatrists, whose [labor] agreements include staffing provisions, employment of psychologists along with a commitment to their training has been left up to the shifting judgment of the HMOs. Experience teaches that what is not standardized ultimately doesn’t take place, and as long as this problem is not rectified through a clear, written commitment, a major question mark hovers over the very existence of the profession,” Leus told Haaretz in reaction to Goldberg’s defense.

It should be noted that in a Haaretz article about a year ago, the Health Ministry’s director of mental health services, Dr. Gadi Lubin, who is a psychiatrist, acknowledged that the ministry would not “pretend to dictate to the HMOs exactly what the mix should be” among those providing mental health services. The exception is psychiatrists, who based on what has made public, are to be given about a third of the staff positions.

Health Ministry sources are saying now that there still is no intention of requiring that a third of the positions be reserved for psychiatrists. But the ministry’s major policy document, “Standards for Mental Health Clinic Services,” states that if a clinic is not headed by a psychiatrist, another psychiatrist should be designated the medical director of the facility. That means a certainty that a psychiatrist will be involved in the clinic’s operations. Other than that, there is no specific professional that the Health Ministry is requiring to be on staff − and that includes psychologists.

Leus also asked to clarify that it is not his contention that all the psychologists will be fired within a day, but said the decision over whether to have psychologists on the staff of the community clinics will be up to the judgment of the clinic director. Therefore, Leus said, there is nothing preventing the director from laying them off at any time and replacing them with staff from other professions.

With regard to the question of who would be entitled to direct a community mental health clinic, the situation is rather complicated. For his part, Leus provides two different versions of the major Health Ministry policy document, “Standards for Mental Health Clinic Services,” one on which a Haaretz article dated January 1, 2013 was based, stating that the position of clinic directors can be filled by a psychiatrist, social worker, or “someone with a master’s degree from a therapeutic profession licensed by the Health Ministry.” This arguably obscure definition appears to avoid mentioning psychologists specifically, although theoretically even physiotherapists would also fit the description.

Leus also has another version of the document, with the same date and document reference number, which is apparently the text that Goldberg relied upon in her response to his op-ed. On the issue of which professionals are authorized to serve as clinic directors, in this other version, clinical psychologists are explicitly listed among authorized professionals for the top job at the clinics.

This prompts a question, however, as to which version is the official one and why two versions were prepared. Health Ministry staff said the difference is explained by revisions to the document, and the version that does not explicitly mention psychologists is the updated version.

But ministry spokeswoman Einav Shimron said in response: “Any therapeutic professional with a master’s degree can direct a clinic, including a psychologist.” The ministry added: “Every clinic, in accordance with the character of the population [that it serves] requires its own different mix of personnel. In areas with a large number of socioeconomic problems − more social workers. In areas with greater demand for psychotherapy with less of a context of social welfare distress − more psychologists. At a clinic where people with criminal tendencies are treated − criminologists. Each clinic requires a multidisciplinary staff with representation from all of the professions. There are types of intervention that only highly specific professional staff can carry out: diagnostic testing only by psychologists, drug therapy only by psychiatrists, rehabilitative intervention only by social workers. There are types of intervention that any professional with special training can provide, such as psychotherapy. It’s important for there to be representation of all of the therapeutic professions, without designating the numbers of each.”

Bar-On is a clinical psychologist.

Emil Salman