The fatal shooting Monday of Munir Anabtawi, 33, by a police officer who says the mentally ill man from Haifa inflicted minor knife wounds on him is yet another illustration of Israel’s failure to successfully treat people with mental illness.
Though Anabtawi’s death is an extreme case, it’s a consequence of a much broader phenomenon that impacts the lives of hundreds of thousands of Israelis – those who suffer from mental illnesses and their families, who must cope for years with the lack of an appropriate solution for patients in the community who are deteriorating.
“The tragedy of Munir Anabtawi and his family is an exact reprise of the deaths of Shirel Habura a year ago, and of Yehuda Biadga two years ago,” says Rivi Tzuk, the chairwoman of Otzma – the National Forum of Families of the Mentally Ill. “Extreme and dangerous psychotic episodes are rare and don’t happen suddenly; they are crisis situations that can be treated, just as we can offer immediate help to someone who has chest pains or is already having a heart attack. It is this simple analogy that Israel has failed to implement. There are no solutions in Israel for mental-health crisis situations, as there are in developed countries.”
Anabtawi’s life wasn’t easy, nor was that of his family. The routine imposed on them by his illness was characterized by a ritual of repeated psychiatric hospitalizations and releases (what the health system refers to as the revolving door). In between hospitalizations there was difficulty keeping him in balance, resulting in psychotic attacks that led to repeat hospitalizations.
Israel’s mental health system cannot cope successfully with this group of people because there is almost no transition layer of support and treatment between hospitalization and treatment in community clinics. As a result, maintaining a routine that includes keeping the patient balanced and the illness under control is a serious challenge for patients and their families. It requires the patient’s cooperation, proper treatment, careful adherence to the drug protocol and supportive medical follow-up. When these patients’ condition starts to deteriorate, the families have no one to contact to try to halt it.
“In Israel there are 150,000 people with illnesses that could potentially spark a psychotic episode,” says Tzuk. “When you add to this the families of those patients, we come to hundreds of thousands of people in this situation. It’s something you live with all the time; it’s the life experience of hundreds of thousands of people who, even if they haven’t yet encountered this situation, walk around with the fear that it could happen and there won’t be a solution.
“Ninety-seven percent of people with serious mental illness are in the community, with only 3 percent hospitalized at any given time. Shooting incidents like that of Munir Anabtawi are extreme incidents, but there are many other terrible traumatic incidents that happen and the families have no one to turn to,” Tzuk says.
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Lacking available professionals to help with treatment and halting deterioration of the mentally ill in the community, the families’ distress and frustration leads them to the solution of last resort – calling the police – which forces police officers to deal with a mentally ill population that they aren’t trained to address.
“It starts with the fact that the country’s health care networks have not developed mental health services that are adapted to crisis situations. There are no intensive plans, follow-up, initiated contact or home visits to patients, and you can’t increase the number of therapy sessions if necessary. There are long waits for appointments,” says Tzuk. “As a result, when there’s a crisis there’s no one to turn to. The system is so lacking that it cannot respond in time and stop a decline when it starts.”
The difficulties continue as the patient’s situations deteriorates and becomes a crisis. “Forced hospitalization is not a good solution but it’s better than having a policeman come and kill you. But making that happen has become impossible. The district psychiatrists [who have the authority to order an examination or hospitalization] won’t order an examination based on families’ complaints; they require an opinion from a professional. But it’s a vicious cycle; if I could bring him to a professional then I wouldn’t need to turn to the district psychiatrist.
“It’s come to the point where professionals say, ‘If it’s urgent, call the police.’ And thus we slowly slide into a situation in which parents and policeman don’t know what’s happening. Because there is nothing preventing an escalation they simply sit and let it get extreme so there will be grounds for forced hospitalization. The policemen are also victims of this situation,” Tzuk says.
According to Dr. Zvi Fishel, chairman of the Israel Psychiatric Association, Anabtawi’s death was “the end of a chain of failures that begins with stigma against psychiatric patients, continues with underfunding of the psychiatric system in Israel, a lack of personnel and mechanisms for home care and intervention in crises, and ends with the impossible encounter between policemen and a patient who looks psychotic. The patient dies, the policeman is undoubtedly traumatized and the whole country loses.”
In a letter Fishel wrote to Police Commissioner Yaakov Shabtai following the killing, he wrote, “This is a repeat incident that points to the difficulty policemen have coping with the mentally ill. It stems from relating to our patients like a terrorist or criminal that the police must ‘neutralize.’” Fishel repeated a suggestion he’d made half a year ago to immediately train policeman to deal with the psychiatric population and set up dedicated intervention teams to deal with emergencies.
Israel’s mental health system is chronically underfunded. In 2019 it was allocated only 3.8 percent of the expenditure on public health, compared to 10 percent or more in other Organization for Economic Cooperation and Development member states. This comes on top of the fact the public health expenditure in Israel in general is 2.5 percent lower than in other developed countries. While in these countries around a third of the mental health budgets are invested in preventing crises, in Israel this category doesn’t exist at all.
One effective solution would be the establishment of mobile crisis teams composed of professionals who would make home visits to evaluate patients and detect situations of distress. The staff arrives at the patient’s home, calms him down, diagnoses his condition, and works to determine the course of treatment. In Israel, there is no such system, other than one individual initiative that was described in a Haaretz article in 2017.
Dr. Schmulik Pagirsky, director of psychological services and of the home visiting program at Abarbanel Mental Health Center in Bat Yam, said that following that article he had gotten a flood of responses, including from families who brought their ill relatives to the hospital to meet Pagirsky – testimony to the need for such a service.
Pagirsky had worked for seven years in New York as part of a mobile crisis team – a mobile psychiatric unit prepared to meet patients anywhere – at their home, workplace or school. Such crisis teams also operate in other countries, like Britain and Holland. He says the deaths of Anabtawi and the others could have been prevented if Israel had a home visit system that brings professionals to a crisis before it gets out of hand. “The moment things become wild it’s very hard to do anything,” says Pagirsky. “When a policeman comes to such an incident he doesn’t know what to expect and he isn’t trained to deal with it.”
The idea of crisis teams for mental health patients has risen and fallen over the years. It resurfaced again last year following the killing in Jerusalem’s Old City of Eyad al-Hallaq by a Border Police officer in May 2020. Under the auspices of the President’s Residence, an interministerial committee was set up, headed by Labor, Social Affairs and Social Services Minister Director General Victor Kaplan, to examine the interface between law enforcement and the disabled. The committee submitted its recommendations in February; one of its major suggestions was to set up crisis teams.
Such recommendations, however, must go through a battery of procedures before anything comes of them. There are also efforts by the Health Ministry’s mental health department to encourage the health maintenance organizations to develop their own home-visit services. “If we don’t do something, there’s going to be an incident like [Anabtawi’s killing] every few months,” says Tzuk.