Toward the way forward: building an emergency mental health system for Israel
© Schreiber. 2015
Received: 1 August 2015
Accepted: 6 August 2015
Published: 15 September 2015
A number of related changes have evolved over the past 25 years: the development of a truly national disaster mental health service in Israel; progress in the science of risk, resilience and evidence base care for those suffering from traumatic stress related disorders; and the development of conceptual models of population level disaster mental health response in the context of emergency management systems such as the Incident Command System.
In a recent IJHPR article, Bodas, et al. report on the dynamic history of disaster mental health response in Israel, which informed by the all too numerous real world events affecting the region. What is most striking is that the system now in place reflects true “lessons learned” in that problems and issues identified in incidents informed deliberative planning, and the current system reflects many iterations of “lessons observed and learned”. There appears to be commitment across sectors of government in Israel that the mental health consequences of disasters and terrorism are important and a priority. This is advanced thinking and sound policy.
As the system in Israel continues to evolve, additional possibilities are offered for further consideration, based on the author’s US-centric experience, to advance emergency response systems in Israel, the Middle East and around the world.
The recent IJHPR paper by Bodas and colleagues  provides a detailed overview of Israel’s national efforts to develop an emergency mental health system, in light of a series of armed conflicts and terror attacks.
Since it began in the 1980’s, the emergency mental health system in Israel has evidenced considerable change and growth in terms of service delivery settings, coordination, payor/funding mechanisms, scope of services and levels of care. These authors describe in detail how these changes have been influenced by real world events, including the threat of ballistic missile attack involving chemical weapons during the first Gulf War. Other changes were seemingly influenced by changes in organizational structures, distribution of responsibility between local communities and various components of the national government. In its current formation, the system appears to provide a multi-tiered response, focused on on-site services by local teams, support centers that provide services to those presenting, and resilience promotion activities via NGOs and other settings.
This commentary will consider the following aspects of the evolution of the emergency mental health system in Israel: process of change, funding, models and range of services, locations, and timing.
Process of change
What is particularly fascinating to a non-Israeli reader is how the model has been significantly influenced by numerous real world events and how those responsible for the emergency mental health system have adopted a true “lessons learned” approach. For example, following the deployment of the Iron Dome missile defense system, a reduction in direct help seeking was observed, alongside an increase in so called “hotline” use. This required training of the call takers to identify those at higher risk for serious psychological consequences, and such training was then duly provided. Indeed, among numerous innovations, perhaps the most notable is the process innovation of adapting the national emergency mental health system following large scale events.
In many countries, there are “after action” reports and/or large scale recommendations for change. Yet the impact of these after action reports and commission reports is often hard to see in larger countries. Some of the changes in Israel reported by Bodas and colleagues have been sustained and others determined to be less so, so that this candid report is also strikingly refreshing and perhaps unique. In Israel, there seems to be deliberative planning that takes into account issues that truly become lessons learned that produce change and not merely ‘lessons observed’.
Once the emergency mental health planners in the United States and elsewhere recognized the need to go beyond single session debriefing for trauma victims and to include longer, evidence based, interventions (such as Trauma Focused Cognitive Behavioral Therapy), the need to secure special funding for these services became evident. Timely trauma care can provide substantial benefits to the individual, their families and society as a whole, as been observed with timely care for depression in the United States . However, the planners identified that current insurance protocols made financial access to care an additional burden on families, preventing timely use of trauma care . In Israel, the funding scheme for disasters has evolved over time to increasingly make access to care possible through novel partnerships with the single payer health insurance system, NGOs and other partners.
In the United States, since the late 1970s, a novel federal disaster mental health program provides financial support to states following a presidentially declared disaster and is known as the Crisis Counseling Program. However, this program does not typically provide for professional care and those needing professional care after a disaster still face significant financial burdens. Following 9/11, an extension of the Crisis Counseling program called “Enhanced CCP Services”, and more recently the “Specialized Crisis Counseling Services Program”, has expanded on the original non-professional services model and provided a larger array of services. Research on these expanded CCP services found beneficial effects , and suggested their broader expansion , http://www.phe.gov/Preparedness/legal/boards/nprsb/Documents/nsbs-dmhreport-final.pdf). It is not year clear to what extent the US Affordability Care Act (ACA) will also address financial barriers to trauma care. In the US, the major NGO providing disaster mental health services, the American Red Cross, does not typically provide definitive care and services are restricting to 2 crisis intervention sessions and up to 2 follow up sessions. Solving the payer issue to facilitate access to evidence based care remains a challenge.
The article by Bodas and colleagues describes various changes over time in the provision of types and levels of care. For example, in the 1980’s, before research on the lack of salutatory effects of single session debriefing became known, that approach was widely utilized, along with undefined “mental health aid”. Following these findings, other approaches, including notably CBT, have been increasingly deployed. What is not clear however is the extent to which even more recent findings of meta-analyses  and consensus reports  have been incorporated. These have found, for example, that Prolonged Exposure CBT has the best evidence of outcome  in adults and in the case of children, Trauma Focused CBT [7, 8] has the best evidence of outcome. In fact, the provision of services of any kind to children are not mentioned in the Bodas et al. paper and because children may be the single highest risk age group , there is a need to urgently address the needs specifically of children. Interestingly, novel disaster models for services to children have been developed in Israel, but it is not clear if they are being used in the model currently employed  and it is unclear whether a national strategy for the needs of children is operative.
Another known population with significant natural resilience, but also elevated risk, is the responder population. It is not clear from the Bodas et al. article how they are served in the Israeli emergency mental health system—either in services provided by the Home Front Command or elsewhere. This may be a gap requiring further work. In the US, a model known as ‘Anticipate. Plan. and Deter: building responder resilience’ is one example of a model for providing a comprehensive, stepped care approach to responders and health care workers in particular (https://iab.gov/Uploads/IAB%20Stress-Related%20Mental%20Health%20Issues%20White%20Paper.pdf, http://www.cdms.uci.edu/PDF/resilience-workshop.03222012.pdf, ).
Although the article describes many changes in the programs, many of these appear structural and locational. Beyond the description of use of CBT and non use of Benzodiazepines, it was not clear exactly what type of CBT is being offered, when it is offered, how providers are trained in these models, how this training is funded and if children are also being served with CBTs.
It is not clear exactly what type of CBT is being offered, how providers are trained in these models, how this training is funded and if children are being served. The range of services appears comprehensive, but the article is lacking in sufficient detail to permit further conclusions. For example, the word “resilience” is used frequently to describe program elements and in the “current model” it refers to “on-going efforts to promote public resilience during routine times through resilience centers and other NGOs”. However there is no specific operationalization provided on exactly what “efforts to promote public resilience” means, if it has evidence of effectiveness, and how it is delivered and to whom.
Further, care is described as being provide in a “stigma free” manner, but how is this determined? “Stigma free” is most likely a goal, not a current outcome. Rates of utilization, compared to population level estimates of new incidence or point prevalence of post disaster disorders are not presented, so it is not clear to what extent services are achieving population level “reach” to those at risk. Available epidemiological reviews suggest that between 30–40 % of the population can be at risk for a disorder following a disaster. Often times these outcomes reflect comorbid presentations of PTSD plus another disorder such as depression. However, most of the services seem directed to “anxiety” or distress, not clinical depression or PTSD. The latter can be part of the outcome trajectories for some persons experiencing trauma, including young children, as our diagnosistic systems increasingly recognizes changes in the expression of PTSD in children 6 and under (http://www.apa.org/pi/families/resources/task-force/child-trauma.aspx). In addition, there is a phenomenon that can be separate from anxiety disorders including PTSD and is known as traumatic grief [11–24]. In children, this can present similarly to PTSD but requires fundamental changes in the way care is provided. Since many of the real world events that Israel has experienced also involve traumatic loss of loved ones, it is not clear from the article to what extent a response to traumatic loss and grief have been included in services provided.
The foci of the evolution of services appear to be related to location of services, with the exception of the addition of tele-health services when the threat of injury while seeking mental health care became a further barrier. More information on these exciting efforts that are “resilience” focused, i.e. pre-event and “public” focused is needed. Indeed, emerging efforts in the United States and elsewhere have begun to focus on models of stepped care which involve early evidence-based mental health triage, brief acute phase intervention for those at risk, with symptoms and desiring care followed by reassessment and then provision of a full course of Trauma Focused CBT, in the case of children for example. In the disaster and terrorism situation, an example of this approach is the so-called “National Children’s Disaster Mental Health Concept of Operations [25–27]. Rather than a “one time, one size fits all” approach, this model allows for allocation of limited professional mental health resources to those at greatest risk using a “floating triage algorithm [28, 29]), provision of timely care (which has evidence of being differentially effective, [30, 31] and access to moderate or longer term care if still required to complete the stepped care continuum.
Location of care
Given the unique nature of the threats encountered and the population distribution coupled with surge demands in hospital emergency departments, the Israeli emergency mental health program has evidenced great changes in locations of care—all informed by lessons learned from real world events. Innovations such as co-locating services with hospital emergency departments were attempted, but then modified or discontinued. Since the observation that many high-risk individuals are present in hospital ED’s, it is not clear whether the discontinuation of the use of these the modified ED sites has been beneficial. It is also unclear why ambulances were seemingly used to transport individuals with primary anxiety unless they also were physically injured and required ambulance transport. This may reflect Israel-specific cultural or organizational considerations.
Despite changes over time, the basic model seems to a variant of a stand-alone mental health clinic. referred to as “resilience centers” or by some other terms, they represent largely stand alone clinical settings. One wonders to what extent the inclusion of other settings such as primary care, schools, shelters, work settings and among responders of various types have been included and whether adequate attention has been given to coordination between these settings. Although tele-health is mentioned, other innovations in disaster mental health might be considered to further improve access to care and population level “reach”, which remains elusive in the US  and apparently in Israel as well. These include the use of Internet based interventions  and other interventions for definitive clinical depression and PTSD, which already exist. Provision of care either in the home via tele-health or Internet based interventions or in more routine “disaster systems of care” [26, 34] would further extend the reach that has been so challenging in disasters.
The system of disaster mental health in Israel has demonstrated considerable growth and evolution in the last 25 years and reflects collaborations across many different levels and partners. At its most important, the article by Bodas et al. outlines a national commitment and recognition of the psychological impact of chronic conflict and terrorism. The emergency mental health program has evidenced multiple changes and demonstrates an aggressive “lessons learned” process. Challenges such as timing, service delivery settings, models of care, payor/funding and coordination issues were reviewed. As the program moves forward into the future, recommendations include broader inclusion of “disaster systems of care” [26, 27] to include re-engaging the emergency medical system and hospitals, schools, child care, disaster relief, first responders, and emergency management across all sectors of government. Recommendations also include an increasing focus on populations beyond an exclusive focus on symptomatic individuals, to sub-populations including all children impacted by conflict, those with prior trauma or mental health history, traumatic exposure, communities vs individuals, and responders broadly conceived. An adult and child emergency mental health CONOPS continuum of care approach, that better integrates preventative efforts, acute phase response coupled with rapid triage in primary touch points or disaster systems of care and access to evidence based treatments for adults and children [26, 27] is recommended for consideration, as the program moves forward into the future.
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- Bodas M, Ben-Gershon B, Rubinstein Z, Bergman-Levy T, Peleg K. The evolution of the emergency mental health system in Israel - from the 1980’s until today. Isr J Health Policy Res. 2015;4:25.PubMed CentralView ArticlePubMedGoogle Scholar
- Katon W, Unützer J, Wells K, Jones L. Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. Gen Hosp Psychiatry. 2010;32(5):456-64. doi: 10.1016/j.genhosppsych.2010.04.001. Epub 2010. May 7. PMID: 20851265.
- Norris FH, Bellamy ND. Evaluation of a national effort to reach Hurricane Katrina survivors and evacuees: the crisis counseling assistance and training program. Adm Policy Ment Health. 2009;36(3):165–75. doi:10.1007/s10488-009-0217-z. PMID: 19365722. Epub 2009 Apr 14.View ArticlePubMedGoogle Scholar
- Crisis Counseling Program Needs Improvements. Federal Efforts Help States Prepare for and Respond to Psychological Consequences, but FEMA's. GAO-08-22: Published: Feb 29, 2008. Publicly Released: Feb 29, 2008.Google Scholar
- Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI. Early psychological interventions to treat acute traumatic stress symptoms. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD007944. doi: 10.1002/14651858.CD007944.pub2. Review. PMID: 20238359
- Institute of Medicine. (2008). Treatment of post-traumatic stress disorder: An assessment of the evidence. Institute of Medicine.Google Scholar
- Cary CE, McMillen JC. The data behind the dissemination: A systematic review of trauma-focused cognitive behavioral therapy for use with children and youth. Children Youth Services Rev. 2012;34:748–57.View ArticleGoogle Scholar
- Gillies D, Taylor F, Gray C, et al. Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents. Cochrane Database Syst Rev. 2012;12:CD006726. http://dx.doi.org/10.1002/14651858.CD006726.pub2.PubMedGoogle Scholar
- Wolmer L, Hamiel D, Barchas JD, Slone M, Laor N. Teacher-delivered resilience-focused intervention in schools with traumatized children following the second Lebanon War. J Trauma Stress. 2011;24(3):309–16. doi:10.1002/jts.20638. Epub 2011 May 25.View ArticlePubMedGoogle Scholar
- Schreiber MD, Shields S, Coady J, Perez J, Formanski S, Sims L, et al. Toward the way forward: Developing Responder Resilience using Anticipate, Plan and Deter. Manuscript forthcoming, 2015.Google Scholar
- Cohen J, Mannarino A, Deblinger E. Trauma-Focused CBT for Children and Adolescents: Treatment Applications. New York: The Guilford Press; 2012.Google Scholar
- Crisis Standards of Care. A Systems Framework for Catastrophic Disaster Response. Washington: The National Academies Press; 2012.Google Scholar
- National Biodefense Science Board. Disaster mental health recommendations: report of the disaster mental health subcommittee of the national biodefense science board. Nov. 18, 2008. Available at: http://www.hhs.gov/aspr/conferences/nbsb/dmhreport-final.pdf Accessed: May 5, 2009.
- Perez J, Coady J, DeJesus E, McGuinness K, Bondan S. Operation Unified Assistance population-based programs: US Public Health Service and international team. Mil Med. 2006;1:S53–8.View ArticleGoogle Scholar
- Pynoos RS, Schreiber MD, Steinberg AM. of terrorism on children. In: Sadock BJ, Sadock VA, editors. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, vol. 2. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 3551–64.Google Scholar
- Schreiber M, Gurwitch R. Listen, Protect, and Connect: Psychological First Aid for Children and Parents. Los Angeles: University of California Los Angeles, School of Public Health; 2006.Google Scholar
- Schreiber M, Gurwitch R, Wong M. Listen, Protect, Connect—Model & Teach: Psychological First Aid (PFA) for Students and Teachers. Los Angeles: University of California Los Angeles School of Public Health; 2006.Google Scholar
- Schreiber M Anticipate Plan and Deter: Developing personal resilience strategies for workforce and families. Unpublished manuscript, 2010. Forthcoming.Google Scholar
- Schreiber MD, et al. Disaster mental and behavioral health. In Koenig KL & Schultz CH, editors, Disaster medicine, Second Edition. Cambridge, UK: Cambridge University PressGoogle Scholar
- Shalev AY, Ankri Y, Israeli-Shalev Y, Peleg T, Adessky R, Freedman S. Prevention of posttraumatic stress disorder by early treatment: results from the Jerusalem Trauma Outreach and Prevention Study. Arch Gen Psychiatry. 2012;69(2):166–76.View ArticlePubMedGoogle Scholar
- Stein BD, Jaycox LH, Kataoka SH, Wong M, Tu W, Elliott MN, et al. A mental health intervention for schoolchildren exposed to violence: a randomized controlled trial. JAMA. 2003;290(5):603–11.View ArticlePubMedGoogle Scholar
- Thienkrua W, Cardozo BL, Chakkraband MLS, et al. Symptoms of posttraumatic stress disorder and depression among children in tsunami-affected areas in southern Thailand. JAMA. 2006;296:549–59.View ArticlePubMedGoogle Scholar
- Ursano RJ, Fullerton CS, Weisaeth L, et al. Public health and disaster mental health: preparing, responding, and recovering. In: Ursano RJ, Fullerton CS, Weisaeth L, Raphael B, editors. Textbook of disaster psychiatry. London: Cambridge University Press; 2008.Google Scholar
- Wolmer L, Hamiel D, Laor N. Preventing children's posttraumatic stress after disaster with teacher-based intervention: a controlled study. J Am Acad Child Adolesc Psychiatry. 2011;50(4):340–8. doi:10.1016/j.jaac.2011.01.002. 348.e1-2, Epub 2011 Feb 25., PMID: 21421174.View ArticlePubMedGoogle Scholar
- Mace SE, Sharieff G, Bern A, Benjamin L, Burbulys D, Johnson R, et al. Pediatric issues in disaster management, part 3: special healthcare needs patients and mental health issues. Am J Disaster Med. 2010;5(5):261–74. Review. Similar articles.PubMedGoogle Scholar
- Schreiber M, Pfefferbaum B, Sayegh L. Toward the way forward: the national children's disaster mental health concept of operations. Disaster Med Public Health Prep. 2012;6(2):174–81. doi:10.1001/dmp.2012.22.View ArticlePubMedGoogle Scholar
- Merritt Schreiber, PhDcorrespondenceemail, Sandra Shields, LMFT, ATR-BC, Stephen Formanski, PsyD, Judith A. Cohen, MD, Lauren V. Sims, BS. Code Triage: Integrating the National Children's Disaster Mental Health Concept of Operations Across Health Care Systems. December 2014 Volume 15, Issue 4, Pages 323–333. Published Online: November 17, 2014. DOI: http://dx.doi.org/10.1016/j.cpem.2014.09.002.
- Schreiber M. Learning from 9/11: toward a national model for children and families in mass casualty terrorism. In: Daneli Y, Dingman R, editors. On the Ground After September 11: Mental Health Responses and Practical Knowledge Gained. New York: Haworth Press; 2005. p. 609–2005.Google Scholar
- Institute of Medicine. Crisis standards of care: a systems framework for catastrophic disaster response. Washington, DC: The National Academies Press; 2012.Google Scholar
- Shalev AY, Ankri Y, Israeli-Shalev Y, Peleg T, Adessky R, Freedman S. Prevention of posttraumatic stress disorder by early treatment: results from the Jerusalem Trauma Outreach And Prevention study. Arch Gen Psychiatry. 2012;69(2):166–76. doi:10.1001/archgenpsychiatry.2011.127. PMID: 21969418. Epub 2011 Oct 3.View ArticlePubMedGoogle Scholar
- Ruggiero KJ, Price M, Adams Z, Stauffacher K, McCauley J, Danielson CK, Knapp R, Hanson RF, Davidson TM, Amstadter AB, Carpenter MJ, Saunders BE, Kilpatrick DG, Resnick HS. Web Intervention for Adolescents Affected by Disaster: Population-Based Randomized Controlled Trial. J Am Acad Child Adolesc Psychiatry. 2015 Sep;54(9):709-17. doi:10.1016/j.jaac.2015.07.001. Epub 2015 Jul 11.
- Fagan J, Galea S, Ahern J, Bonner S, Vlahov D. Relationship of self-reported reported asthma severity and urgent health care utilization to psychological sequelae of the September 11 terrorist attacks on the World Trade Center among New York City area residents. Psychosom Med. 2003;65(6):993–6.View ArticlePubMedGoogle Scholar
- Ruggiero KJ, Resnick HS, Acierno R, Coffey SF, Carpenter MJ, Ruscio AM, et al. Internet-based intervention for mental health and substance use problems in disaster-affected populations: a pilot feasibility study. Behav Ther. 2006;37(2):190–205. Epub 2006 Mar 27.View ArticlePubMedGoogle Scholar
- Weedn V, McDonald M, Locke S, Schreiber M, Friedman R, Newell R, et al. Managing the Community Response to Bioterrorist Threats. IEEE Engineering in Medicine and Biology. 2004;23(1):162–70.View ArticleGoogle Scholar