Are a person’s origins likely to affect the quality of mental-health services he receives? Does it matter whether you’re an Ashkenazi Jew with roots in Europe, or a Mizrahi Jew with roots in the Middle East or Africa?
It apparently does. In our experiments we have tried to understand the implications of Israel’s growing socioeconomic gaps and the quality of mental health services at clinics across the country.
This is of special interest because a key reform is set for July. Mental health professionals will have to examine the quality of services they provide to various population groups in Israel.
Social-psychology research shows that people’s community or social identity has a major impact on how they perceive inequality. According to studies on power relationships, for example, one factor that contributes to inequality and discrimination is the bias of members of dominant groups. This originates in the unconscious wish to maintain the status quo and power. It’s us-versus-them thinking.
Such biases are often expressed as stereotypes — discrimination against or inattention to weak groups. In our study, the question was whether this thinking may also affect mental health therapists when they interact with patients.
A session with a mental health professional often involves two people from social groups with a power differential. Thus the question arises whether community identity influences the quality of care.
In our study published last month in the journal Social Psychological and Personality Science, we tested how the social and communal identity of the therapist and patient affect the quality of their first encounter.
The study, funded by the National Institute for Health Policy and Health Services Research, included 122 patients who identified themselves as Ashkenazi or Mizrahi. There were 38 therapists who identified themselves as Ashkenazi (there were not enough Mizrahi therapists, but our research includes some).
All patients came for mental health treatment at public clinics at three cities in central Israel. Each had one session with a therapist, who then determined the patient’s mental health status.
In addition, we asked the therapists and patients to fill out questionnaires on the connection established during the session, a major component for assessing the quality of the meeting. (Answers included statements such as “I felt that we understood one another” and “I felt that the therapist/patient liked me.”)
Right after the session the patients were interviewed by a member of the research team, using a structured psychiatric interview used as an objective measure for diagnosis. A comparison of the structured-interview diagnosis with the therapist’s diagnosis let us assess the therapist’s accuracy.
According to the results, the therapists assessed their Mizrahi patients significantly poorer — terms such as “uncooperative,” “less likable,” “less goal-oriented” — than they did their Ashkenazi patients. Their attitudes were significantly more negative toward Mizrahi patients — they described them as less warm, less wise, less friendly and more hostile.
Also, we discovered that therapists made more errors in diagnosing Mizrahi patients than Ashkenazi ones. This happened, for example, in cases of depression, the most common problem both at the clinic and in the community. The therapists made twice as many over-diagnoses (diagnosing a condition that the patient did not suffer from) or under-diagnoses (not diagnosing a condition the patient suffered from).
Just like in America
The patients themselves, both Mizrahi and Ashkenazi, did not differently assess their connection to the therapist based on their affiliation. There were no significant differences in the severity of the psychological problem or the socioeconomic status of the two groups of patients.
It should be noted that accurate diagnosis is the basis for treatment, without which a patient’s problems cannot be addressed. A wrong diagnosis can lead to wrong treatment that can perpetuate a patient’s problems.
In our study published in the Israel Journal of Psychiatry in 2012, we found that when Ashkenazi psychology students addressed a case of a patient with symptoms of depression — half of them receiving patients with Ashkenazi names and half with Mizrahi names — they assessed the Mizrahi patients more negatively and as less cooperative.
Even more significantly, this finding was replicated when we tested Ashkenazi therapists in community clinics. They too showed negative attitudes toward Mizrahi patients, based only on the names they were given, not on clinical detail.
The results of these and other studies show that the community and social identity of patients can affect the attitude of therapists, the results of their encounters and the diagnosis.
This is most likely based on biases including stereotyping the culture, lives and needs of patients. A therapy session, which already involves a power difference, can exacerbate these biases, especially when the patient belongs to a minority and the therapist to a majority.
Likewise, studies in the United States show that white therapists see black patients as less cooperative and more hostile. But therapists must provide service appropriate to the cultural background of each patient.
This task isn’t simple, especially when the patient and therapist have different cultural backgrounds. Therapists usually get minimal or no training in dealing with people from other cultures, and the cultural suitability of various treatments for various population groups has not been assessed.
This point is particularly important because in most Western countries, including Israel, most therapists come from strong segments of society, or from the majority. In Israel, most are Ashkenazi; only a few are Mizrahi, Ethiopian or Arab.
In his book “Human, All Too Human,” Nietzsche notes how everywhere he saw a living creature he saw a will to power. It seems that in the treatment room, which should be a haven for the weak, this power is brought to bear.
Our moral duty as therapists is to overcome our biases and become aware of the psychological process that causes them. This is the first step to improving the treatment we give to those seeking our help.
Dr. Ora Nakash is a clinical psychologist and assistant professor at the School of Psychology at the Interdisciplinary Center Herzliya. Prof. Tamar Saguy is a social psychologist, researcher and lecturer at the School.
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