indications for mental health planning for children in israel

INDICATIONS FOR MENTAL HEALTH PLANNING FOR CHILDREN IN ISRAEL*

HERSCHEL ALT Execulive Director, Jewish Board of Guardians, New York, N . Y.

is my purpose to outline some of the social and psychological factors IT in the child welfare situation in Israel and consider how these may influence the planning of mental health programs. I believe this kind of examina- tion might not only be of value in understanding the needs of children in Israel, but might also yield helpful suggestions for mental health planning in other nations or regions.

I have assumed that planning in this field must proceed from a broad base and must take into account not only needs which are reflected in mental illness, delinquency and similar phenomena, but also the basic cultural values and social and economic organization of the area under consideration. Until the more basic elements in our social structure are re-examined to see how far they are consistent with mental health values, we are working a t the periphery rather than the heart of the problem. Once we recognize the important part these general factors play both in causation, prevention and treatment, we realize that mental health programs must be designed with full consideration for the particular culture and needs of the human beings they are intended to serve.

For many reasons, Israel presents an unusual opportunity for observing the interrelationship between historic factors, national purpose, immediate and long-term social issues and the more personal problems of its people.

No doubt, other nations a t different times in their history have faced grave social and psychological issues. Rarely, however, have the problems been so complex, their roots so clearly discernible, and the degree of aware- ness so great. Rarely too has planning proceeded on so many fronts, a t such rapid pace and with such clear purpose.

Israel describes the basic problems which now confront it as peace, ab- sorption and economic reconstruction. The interrelationship of these is apparent. The preservation of peace calls for national defense measures which in themselves are costly. Admission of large numbers of new people may be a positive factor in national security but also creates serious economic problems.

Israel has continued to see itself as a beleaguered nation, one whose people have no choice except to continue to fight with all the means a t their com- mand until its sovereignty is acknowledged and respected. Although many

* Presented at the 1950 Annual Meeting.

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106 MENTAL HEALTH PLANNING FOR CHILDREN IN ISRAEL

of its people have been subjected to inhuman deprivations in Europe, and now in Asia and North Africa, they seem nevertheless to be able to face difficulties with extraordinary poise and dignity and are plan fully striving to establish a state in which the inhumanities they have suffered can never recur. Common purpose and common problems are reflected in the deep sense of solidarity which is the dominant note in human relations.

It seems hardly necessary to point out that neither this discussion nor the original study upon which it is based represents anything more than a very partial statement of the problem. It is impossible to generalize about a country like Israel, with its many diverse nationality and cultural strains and the many differences in the ideology and experience of its population.

More knowledge might have led to different conclusions. Then too other observers might have attributed different meaning to the same phenomena. What is here set forth must be taken as impressions based on limited observations by professional people with particular kinds of experience.'

Social Factors. The most crucial factor in the present social scene in Israel is the rapid growth of the population due to the extraordinary rate of new immigration, and the social, economic and psychological problems with which it is accompanied. Unrestricted immigration is a basic element in the present national policy. Since the majority of its people fled from per- secution and tyranny in other lands, Israel cannot bring itself to consider any denial of asylum no matter how serious the immediate consequences might be.

During the period between the termination of World War I in November 1918 and the establishment of the State in May 1948, the Jewish population increased tenfold-from 60,000 to 625,00(rtwo thirds of the growth being due to new immigration and the remainder to a natural increase. During the eighteen months following the establishment of the new state, the population rose from 625,000 to 1,000,000. Immigration continues a t the rate of 200,000 per year, and it is expected that within the next four-year period, the population will again treble.

Few countries have ever faced this rate of growth. Even under favorable circumstances, this would call for more jobs, homes, schools, hospitals and social agencies. I n Israel, where people come from many lands with different ways of life and habits of thought and where all the immigrants have been subjected to hardships over many years, problems are much deeper and more complicated.

The need to provide full employment for the rapidly expanding population is perhaps the number one social problem facing the nation. The govern-

1 The facts referred to in this discussion are largely based on a study of child welfare made in Israel in the summer of 1949 by Dr. Peter Neubauer and the author with the assistance of Miss Aline Cohn. T h e study was sponsored by Hadassah and made in cooperation with the Israeli Government,

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ment program seeks to provide increased employment through construction and public works, through agricultural settlement and private industry. However, private industry does not seem to be growing fast enough to provide its share of the necessary jobs.

Second in importance to employment is the problem of housing. Although there are 80,000 persons living in immigrant camps because of lack of perma- nent housing, it is remarkable that this figure is so low considering the tre- mendous number of new arrivals. New houses are being built rapidly, but it is not likely that a balance between need and supply will be achieved for some time. Within the housing already available there is a good deal of over- crowding.

Although no figures on nutrition or other indices of physical well-being were available, it was our impression that while standards of living are gen- erally quite modest and show much less variation between the various vocational groups than is usual, the conditions of the general population continue to be moderately favorable. The austerity program of food control, wage and price regulations and national taxation help to maintain an equitable distri- bution of buying power as well as food and other consumers’ goods.

Public assistance or outdoor relief appears to be strikingly inadequate compared with standards in the United States. In urban communities relief per week per family may be as low as one or two Israeli pounds. In addition, however, familips receive food distributions provided by municipal or state or international agencies. School lunches are provided for children in neqd; various forms of assistance are provided through the Federation of Labor to its own members; and there is evidence of a good deal of mutual aid. In spite of these ameliorating factors, it is our impression that families in which the breadwinner is unemployed or incapacitated may experience serious hardships.

One unusual problem stems from the changing character of the immigration. During the three decades preceding the establishment of the State, most of the immigrants came from Eastern and Western Europe, and while there were differences in culture and general social orientation among them , on the whole they brought to Israel a good deal of the same kind of faith, hope and aspiration. Their culture had relatively common roots in Jewish life in Western and Eastern Europe. By the summer of 1949, immigration from Europe sharply declined; most of the population of the Displaced Per- sons camps in Europe had been transferred to Israel and many of the Euro- pean countries now restrict migration of their Jewish nationals.

Consequently, most of the immigrants now arriving are from North Africa and Asia, and they bring an almost entirely different cultural and social orientation. The difference extends to physical appearance, dress and language. Settlement in Israel also has a different meaning for them which tends


to be weighted by concrete practical considerations in contrast with the idealistic motivation of those who came from Europe.

These differences in attitudes and in habits of thought bring with them additional problems of social adjustment, not only for each member of this group, but also as between themselves and the rest of the population. Israel is beginning to recognize the importance of this problem, but as yet has not adopted any specific programs to deal with it.

Child-Rearing Values. The diversity of social origins and background of the population is reflected in differences in family structure and relationships and in the character of the child-rearing function. These differences can be seen in many aspects of child life: in what is expected of children, in the division of responsibility for child care between family and community, and in child-caring methods and values.

For example, in the Moroccan family, which contributes so heavily to child delinquency, the father is a Jehovahlike person. He is all-powerful with authority extending almost to life and death. The boys are highly prized and the girls accorded little worth.

In sharp contrast is the pattern of child care which has developed in the kibbutz or cooperative agricultural settlements. The kibbutz embodies the social and psychological ideals of the early pioneers and reflects the necessities which confronted them as they settled in Israel. The Jews who came to Israel after the pogroms in Russia and other parts of Central Europe in the early years of the present century had been dwellers in the densely populated cities of the Pale. They had been forced to live in overcrowded ghettos, restricted as to choice of occupation, prohibited from engaging in agriculture or manufacturing and, therefore, driven into petty trade and minor professional vocations which they considered less productive than those based on physical efforts.

T o them Israel represented an opportunity to create a social order in which the cornerstones were democratic process as the basis of social control, cooperative economic endeavor and useful manual work. The pioneers were men whose purposes were characterized by the highest degree of earn- estness, interest in the common good and readiness to invest oneself to a degree amounting to almost grimness and inflexibility. The part which neces- sity played in sustaining these ideals should not be overlooked. The early pioneers found a barren country which could only be made productive through extraordinary physical effort. No ,hired labor, whatever the economic incentives, would have transformed the arid desert into orchards and gardens. This called for a measure of energy which would only flow from the deepest convictions and devotion.

I t has become common knowledge that from birth children in the kibbuiz live apart from their parents, but we must not assume from this that the

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difference between the pattern of child rearing in the kibbutz.and that of our Western urban family is an absolute one. Separation is a relative concept, and separation as it appears in the kibbutz should not be thought of as identical with that of children who are brought up in foster homes or institutions away from their parents. Perhaps a brief description of the pattern of child care in the settlement will clarify this distinction.

After the mother leaves the hospital, the newborn baby is placed in the community nursery. Thereafter the responsibility for his care is shared between the community and the family. As the child grows older, the community assumes an.increasing responsibility for the child’s care and education. During the nursing period the mother spends a good part of the day with her baby. After weaning takes place, the mother returns to work and her visits to the nursery and the time she spends with her child are reduced. She may, however, work in the kitchen, laundry or poultry house nearby and see the child four or five times a day.

After the first year, the direct care of the child becomes more completely the responsibility of the nurse, and the mother’s visits as well as the time she spends with him are reduced further. As the child grows older, he is made much more conscious of his membership in the group, whether it be in the nursery, the children’s house or the school. What must not be overlooked, however, is that both father and mother continue to see the child one or more times each day during their leisure hours and their visits may amount to as much as two to three hours on working days and many more on the Sabbath.

To a degree without parallel, the material, intellectual and spiritual resources of the settlement are devoted to the care and education of its children. The child enjoys the best which the community can provide for him, even though this may involve serious sacrifices on the part of the adults.

We do not know of any authentic study of the effects of this pattern of child rearing, nor do we have any clear symptom picture which might signify difficulties in growth or personality development. Some well-known symptoms, such as thumb-sucking and enuresis, do appear in the early years, but it is difficult to say whether these are more prevalent among children reared in the kibbutzim than where other methods of child rearing are employed. The same general observations apply to the development of these children during their later years. We do not believe any generalizations are now possible. We also feel strongly that judgments of the value of this form of child rearing as against others should be withheld until the results of complete studies are known. We are convinced that the form of child rearing employed in the kibbutz seems well designed to produce adults for cooperative living.2

2 It is noteworthy that the kibbutz turns to psychiatrists and child guidance workers for treatment of children and pays for these services out of communal funds. It is also significant that i t may arrange


While the influx of new immigrants has reduced the ratio of the population in agricultural settlements to that of the country as a whole-now only 12 to 15 per cent of the inhabitants live in the kibbutz-nevertheless the influence of the kibbutz on child education and child rearing remains dominant in the ideology of the nation.

What impresses itself most strongly upon the American observer is the apparent clarity of goals for children in Israel and the more direct relationship between goals and the methods employed to achieve them.

Children enjoy first priority in everyone’s thoughts and feelings. The child is identified with the future of the state and is the focus of social planning. Without questioning the value of this emphasis, we must recognize its potential limitations. The emphasis on the child may tend to focus services on the child himself rather than on his family. As has been true of the development of social work in our own country, there is some danger that in Israel services for children apart from their families may take precedence over services which safeguard and strengthen the family itself.

The emphasis on the contribution of each individual to the common good as a social ideal has been reinforced by the present hardships of everyday life. Present-day pressures coupled with the idealism of the early pioneers and orthodox religious values have also led to an extraordinary emphasis on conformity, on productivity, on learning and on an abhorrence of waywardness. These attitudes lend a sober quality to educational endeavor and practice and sometimes are reflected in the views of educators that the leisure time of children should be devoted to cultural activities rather than to play.

The fear of waywardness in children is general and widespread and strongly colors the attitudes of public officials and social workers. It is reflected in doubts about the capacity of families to handle problems of their children, and in some lack of faith in the children of the new immigration. The abhorrence of waywardness undoubtedly gains force from one of the legacies of the mandatory government, the absence of a compulsory school attendance law. I t would be an interesting study to trace the complex of psychological attitudes which have resulted from this. Although voluntary school attendance has been unusually high and may have reached as much as 90 per cent there has nevertheless been very deep concern about those children who have had little schooling and who have been seriously handi- capped in character development as well as in vocational education.

Children with Special Dt3culties. The meaning of some of the social and

for individual therapy for adult members of the group who face difficulties in adjustment. A few of the teachers and children’s nurses have undergone personal analysis. I mention this because we may think of the kibbutz as a community in which the group dominates the individual, and individual functioning is clearly defined and circumscribed. One must not assume that the approach of the kibbutz to problems of human relationship is narrow or rigid.

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psychological factors which we have briefly sketched may become clearer as we see them expressed in the problems and care of children facing special difficulties-the homeless, delinquent and emotionally disturbed group.

Approximately 20,000 children in Israel today are homeless and are given care through two central programs-5,000 through the Children’s Bureau of the Ministry of Welfare and 15,000 through the Youth Aliyah or Youth Immigration Agency. In general, Youth Aliyah is responsible for the education and training of children arriving from abroad without parents, and the Children’s Bureau for those whose families are already in Israel and are considered members of the established community.

The important influence which these services may have on the future well- being of the country can be gauged from the estimate that a t least one third of the young people within the age groups of 15 to 17 in the present population are being reared through the Youth Aliyah program, and approximately 20 per cent of all children up to 14 years of age will be cared for some time during their childhood through the Children’s Bureau or through Youth Aliyah.

Recent years have brought basic changes in the responsibility undertaken by these programs. This is especially true of Youth Aliyah. When this organization was founded fifteen years ago, its task was relatively simple. Its major objectives were to help young people to migrate to Palestine and to arrange for their placement in agricultural settlements. Youngsters were organized abroad into youth groups affiliated with various youth movements. The children were usually 15 years of age or older when they emigrated to Palestine. The majority were without parents, and where parents were alive, they were rarely able to follow the children to Palestine.

In most instances, the youngsters had already achieved a fairly high educational level. They also received a good deal of preparation for their new life, were eager to come, and knew what was in store for them. The number of new children coming was relatively small and they were easily absorbed into the agricultural settlements. On the whole, the cultural and religious background of the children was much like that of the settlement in which they were placed in Palestine.

The young people and children arriving now differ in many respects from those who came earlier. A smaller proportion are coming from Europe. The majority are coming from countries in North Africa and Asia. The children are younger, almost one half being 14 years of age or less. Owing to the conditions in the lands of their origin, most of them have had relatively little or no preparation for coming and are not organized into groups until their arrival in Israel. Furthermore, the educational achievement of the present groups is much more uneven. The number of children arriving in recent years is fifteen times as great as in the earlier period.


This increase in numbers and change in ratios between younger and older children carries with it the need not only for expanded accommodations, but also for different kinds of facilities and educational programs.

Perhaps the most stubborn problem is the one resulting from the change in the character of the family relations of the children. Although the program was originally conceived and planned for unattached youth, a t the present time most of the youngsters have families who are planning to come to Israel; and when these arrive, many problems in relationships appear.

The fact that a majority of the children are now coming from North Africa and Asia means that their language, social and cultural background is often different from that of the kibbutzim in which they are to be placed and educated. I t is not hard to imagine the many psychological and practical problems which such differences create. For example, in an extreme instance it has meant that the madrich (teacher-counselor) spoke one language and the youngsters another, and that they were unable to communicate freely until the young people learned Hebrew.

The serious changes in the task of Youth Aliyah which we have described call for substantial modifications in its methods and procedure. As these adaptations are planned and carried out, it is important that basic objectives of the program be kept in the forefront so that contradiction between policy and practice may be avoided.

Organization of Child-Care Resources. Child care in Israel is founded on a cooperative relationship between the two central agencies and a large number of autonomous institutions and agricultural settlements. The central agency maintains the basic responsibility for the child admitted into its care but relies on the cooperating establishments to provide the actual care and education the child needs, paying the establishment per capita allow- ance for every child placed with it. At present, almost no foster-family care is available and children of all ages, including infants, are placed in group- care facilities.

The child-care facilities include large institutions of children’s villages as well as small privately operated establishments known as “family” institutions. The children’s villages accommodate up to 500 children and are usually operated by philanthropic groups, labor and fraternal organizations organized both in Israel and abroad. In general, younger children are placed in institutions, and young people in kibbutzim or agricultural settlements. There are some exceptions to this rule. Such factors as the imbalance between the kind of facilities available and the age or religious or ideological affiliation of the children have meant that some of the youth are placed in children’s villages and some of the younger children in agricultural settlements.

2,uality of Child Care. As may be expected, there is great variation in the quality of care provided for children in the institutions utilized by the two

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central agencies. Care and education in some of the larger institutions would compare favorably with care of acceptable standards offered in other countries. In these institutions one may find a high degree of planfulness in in- dividualizing the educational needs of the children and educational programs which are broadly conceived and of a high order.

While there is a great deal of emphasis in the educational curriculum in Israel on history, national goals, ethical values and what may be broadly called the humanities, there is an equal emphasis on manual skills, on practical aspects of living and a closeness to the earth. This is true of education in the children’s institution, in the kibbutz and in the regular schools.

The influence of the child-rearing values of the kibbutz can be seen in the emphasis on social responsibility, and on the group as an important factor in achieving this. The group is relied upon as a medium for learning and living. Self-government plans are employed in the classroom and the children are gradually taught to make group decisions about work, recreation and, in some instances, problems of group organization and discipline.

It is obvious that such use of the group is not only consistent with dominant ideological trends, but is also especially geared to meet the unusual problems which the nation faces in the child-care field. I t represents an eco- nomical method and one easily adapted to emergency conditions. I t also incorporates inherent values in child education which we sometimes over- look. I t promotes cooperation, interdependence and certain kinds of identi- fications which are specially needed by the kinds of children cared for. The economy of operation which the group method makes possible may sometimes be carried to extremes, as may be seen in groups that are too large and have insufficient adult supervision.

There is also danger that the child-caring institution will go ahead and apply the principles of child care utilized in the kibbutz without allowing for the differences in the experience of the child in the institution. In the kibbutz there is a great deal of opportunity for close relationship between child and parent. Extraordinary safeguards and protection are thrown around the child from birth. This is in sharp contrast with the experience of the children in the institution, many of whom have already been exposed to extreme psychological deprivations and hardships.

A great deal of reliance is placed on music and art and the making of beau- tiful things as major influences in the development of the child’s personality, and perhaps too little on the importance of human relationships. We saw exhibits of children’s art work which, though of a high order aesthetically, a t the same time revealed a deep sense of inadequacy and loneliness on the part of the children. Clinicians who have worked closely with children in institutions have felt that group care may be premature for some children whose personalities have not yet been well defined and developed. Group


care alone may restrict personality growth and perpetuate emotional im- poverishment. While foster-family and other more flexible forrrs of care may be developed for the younger children, for the older group a t least, group care must continue to be the chief method for a long time to come. It is important, therefore, that the adult leaders understand and make use of all that we know of the dynamics of group formation and function. The differentiation which we make between child care and education seems to be largely absent in the ideology and practice of the child-care agencies, and this can be seen not only in the fact that children live and learn as members of the same group, but also in the function of teacher-counselor or madrich.

The forerunner of the present child-care worker in Israel was the madrich, who organized youth groups, prepared them for life in Israel while they were still abroad, accompanied them to Israel, and continued to guide them after they were settled. He was guide, counselor and teacher. The madrich still carries a great deal of the responsibility for child care and is a key factor in the quality of care provided. H e is responsible for both formal education and guidance of Youth Aliyah groups in the agricultural settlements as well as in some institutions. Although he has been relieved of the formal teaching function for some of the youth groups in institutions, and for most of the younger children, he continues to assume a more active and total responsibil- i ty for molding the child’s character and personality. His approach to child guidance and education is a positive one and is directly related to clearly conceived goals.

The madrich may not be a professional teacher and is selected primarily as a person who embodies the ideals of life in the kibbutz and is capable of communicating them to the young people in his care. Many of the madrichim are persons with unusual abilities and with extraordinary devotion to their tasks. However, the complex problems in education and child guidance which the child-care agencies face make it imperative that the madrich possess not only the kind of personality and ideals which best fit him for the task, but also as much understanding as possible of the problems he is called upon to deal with. Training courses are now offered to madrichim through seminars established by Youth Aliyah. However, a t present, training is in the main focused on increased ability in pedagogical practice. More emphasis on principles of mental hygiene, group dynamics and child welfare needs to be incorporated into the curricula. There are many other problems besides that of training which influence the contribution which the madrich makes to the child welfare program. These involve criteria of selection, working conditions and compensation, and the high rate of turnover among the group.

I n spite of the important place which group care holds, the special needs of children served through child-care programs have compelled attention

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to the value of individualized planning and treatment. Substantial beginnings have been made in providing social and psychiatric study as a basis for the decision to accept a child for placement, for allocation and for treatment. With this has come recognition of the need for better clinical study and more diversified treatment resources. While interest in individualization is increasing, the essential skills available for this purpose are seriously limited.

Our brief review of the more important aspects of child-care practice in Israel suggests two basic and interrelated questions: What is the desired balance between individual as against group planning and care for children of various age levels? What are the values and potential usefulness of a generic child-care function, as compared with one which combines the efforts of a number of specialized professions? The way Israel seeks answers to these questions will not only influence the development of its own child care practice, but should have significance for other lands.

As already indicated, we believe that there are many values in a more generic concept of child rearing which combines skills in child care and child guidance with those of education. We have also stressed the potential usefulness of the group as an element in child care and education. But we do not believe that these values lessen the desirability for more individualization, more diversification in resources and specialized professional care. Our brief survey of the foster-care problem establishes beyond question the need for the development of foster homes and for more flexible, personalized and professional care for children with special difficulties.

Having recognized the need, we must at the same time realizc that it would be well-nigh impossible to make any substantial dent in the problem within the immediate future. Practical realities compel the continued reliance upon group care as the chief resource and upon the madrich as the principal child-care worker.

When we turn to the need for more individualization we must again realize the practical impossibility of providing a sufficient number of caseworkers for individual case study for 20,000 youngsters. More caseworkers are needed to develop the initial plan, to make the decision that placement is required, to choose appropriate facilities, and to guide the treatment of children with special problems. Major responsibility for observation and individualization of the child in the group, however, must still remain with the madrich.

Perhaps what we should strive for in Israel is to develop the generic child- care function to its fullest possibilities and a t the same time to increase individualized planning and to diversify resources as the needs of children require. For the present, we must continue to emphasize the importance of the enrichment of child-care methods by incorporating the understanding and skill of the specialized child guidance professions. For the present,


members of these professions should be used primarily as consultants in planning, in the formulation of child-care procedures, and in the training of personnel.

Delinquent and Emotionally Disturbed Children. During the year ending May 31, 1949, approximately 1320 boys and girls under 16 years of age were dealt with by the juvenile courts in Israel. Based upon the average population during this period, the rate for children ofjuvenile court age is 2 to 3 per cent, which is fairly high compared to the United States, but low compared to the rate in war-torn countries in Europe.

If we compare the incidence of delinquency among children in Israel with that in New York City, we find that the chance that a Jewish child under sixteen will be arraigned in a children’s court is approximately 20 to 30 times greater in Israel than in New York. One need hardly ask whether this means that children in Israel are intrinsically different in endowment, character and propensity to delinquent behavior from Jewish children in New York. Obviously, the answer is “no.” The difference must lie in the social conditions and not in the human material.

As might be expected, there are no estimates available besides those for delinquency of the extent of social and personal maladjustment among children and young people in Israel. As in other countries, emotionally disturbed children are identified in the schools and in families, as well as in the children’s groups in the agricultural settlements. They are identified among the delinquent and homeless groups and they appear in infant and in school health and psychiatric clinics.

From all that we were able to observe and from the data that are available, we concluded that the extent of serious emotional difficulties among children is less in Israel than in our urban communities. At the same time, considering the deprivations to which these young people and children have been exposed, i t is fair to assume that psychological difficulties may exist a t a deep level;. Many members of the Youth Aliyah groups show evidence of serious emotional disturbances. There are few symptoms such as bed-wetting, nightmares, extreme fears or bizarre behavior. The problem often expresses itself in retarded sexual development which takes the form of prolonged latency, in an absence of affect, and in difficulty in establishing relationships with others. It is the opinion of clinicians who work with these youngsters that their problems continue to be masked until the social situation has significantly improved. It is only when the youngster is comfortable and has achieved some identification with a parent person that emotional breakdown takes place and individual treatment then becomes necessary and possible.

One question that is crucial in planning is, How far does the present social- ideological milieu sustain the individual and enable him to function and how far could it be made to do so even more fully? There seems little question

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that the ideological motivations, the feeling of being a t home, the feeling of oneness with one’s fellows all combine to help the individual maintain a balance between inner drives and social demands. However, we are told that those who do break down manifest even deeper disorganization because of the disproportionate role which the social ideal plays in their integration. Their guilt is greater for this reason. When a breakdown occurs, it is almost total in character and is completely overwhelming.

Interrelationship between Treatment and Preventive Programs. In approach- ing the problem of individual treatment we must recall two assumptions implicit in our discussion. The first is that prevention of social and psychological problems is more important than treatment for such problems after they have become established. Measures which safeguard the security and well-being of all children must take precedence over those for treatment of children with special problems. This premise is of special importance in Israel, where so many children have been subjected to great deprivations during their life in other lands and where individual treatment for all is not a practical possibility. We must face the fact that for the majority, healing must come through opportunities for a fuller and happier life and satisfying human relationships, rather than through specialized therapy.

Closely related to our emphasis on prevention is the conviction that as much help as possible should be provided within the framework of the disturbed person’s living situation. A healthy group should be able to tolerate and absorb many deviations in behavior and at the same time offer a large measure of support to its troubled members.

Because of the extraordinary problems which it faces, social services in Israel do and will continue to play a unique role as compared with many countries in our contemporary world. Not only is it true that the recent immigration presents unusual social and economic needs, but it is also true that the settled population is comparatively new and, like the recently ar- rived group, suffered many hardships before coming to Israel and has not yet achieved high standards of economic well-being. Furthermore, since most of the inhabitants enjoy a comparatively moderate or meager standard of living, a broadening of social services would help to provide more security and comfort for the population as a whole. The government has recognized the importance of social services and a large proportion of government ex- penditures are devoted to such purposes. There is also evidence that the concept of social services in the nation is broad enough to include not only health and economic services, but also programs designed to help individuals and groups facing personal, social and psychological difficulties. Substantial beginnings have already been made in laying the foundation for a broad health and welfare program.

The enactment of a compulsory education law during the summer of 1949


and the establishment of a national educational program in the fall'represents one of the first child welfare measures of the new state. Although the present law covers ages 6 to 13, it is hoped that in time the provisions will be broadened to cover the ages 3 to 16.

A great deal of thought and hope has been invested in the possibility of an educational plan which would express national aspirations for children. I t is significant that the Ministry of Education is not only concerned with finding sufficient classrooms and teachers to meet the increased enrollment and with the enrichment and liberalization of the curriculum, but also with the development of extensive extracurricular services to include school feed- ing, playgrounds, school health, social, psychological and child guidance services.

An intergovernmental committee has been actively engaged in the development of a broad program of social security which, when fully imple- mented, will provide a bulwark of protection for individuals and families and will not only add to the security of the population but will be an important factor in the conservation of human resources.

The professionalization of the Social Service Bureaus which have been established in all communities and the broadening of their functions so as to include personal and mental health services will provide another base for the development of protective services for adults and families as well as for children.

The health program is probably the most fully developed social service program in the country in coverage, diversification of facilities and training of personnel. I t is significant that 90 per cent of the infants born in Israel are cared for in the child welfare stations maintained by Hadassah in cooperation with the Government, with the result that Israel has one of the lowest infant mortality rates anywhere in the world. The school health services, which have been almost entirely provided through Hadassah, reach all children in the elementary and secondary schools and, in addition to the usual child health and health education programs, include a child guidance service.

I t is noteworthy that, in at least three phases of the medical program, mental hygiene concepts have been increasingly incorporated. The School Health Service has evolved from a purely medical program to one which gives considerable attention to emotional and personality problems. The same is true of the child health stations where, more and more, the medical personnel, including the nurses, have broadened their professional interest to include mental health issues. A similar development has taken place in the hospital field, where increasing attention is given to psychosomatic problems.

No extra pressure is needed to accelerate the development of basic pre-

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ventive programs. Because of the nature of the social problems which the nation faces, the policy of the government and the interest of the professional groups, such basic programs will be planned and established as soon as it is practically possible. From the standpoint of the discussion, a t least two areas of concern remain: 1) that the pattern and procedures of these large-scale programs be formulated with due regard to mental health values; and 2) that the personnel who will administer them be as fully qualified as possible.

Although we feel that the value of individual psychiatric treatment should not detract from the importance of the interpersonal environment, education and adequate social arrangements as factors in child growth and social adjustment, the need for individual psychotherapy still remains. This need is especially acute in a country in which rapid social changes are taking place and in which so many children have suffered deep deprivations and have been exposed to severe traumatic experiences.

Moreover, there is a direct connection between treatment on an individual clinical basis and broad social programs. I t is through the work with the individual that we can see the impact and gauge the quality and effective- ness of such programs. Clinical services are also important requisites for the training of professional personnel and for research.

Clinical Services for Children. When we turn to the tools for individual treatment we find both a great deal of interest in clinical services and substantial beginnings in the establishment of such activities. These can be found in the programs of specialized child-care agencies like Youth Aliyah, voluntary medical agencies, such as Hadassah and Worker’s Sick Fund, and within governmental ministries such as Health and Welfare. The first Community Child Guidance Clinic was established in Jerusalem in Septem- ber 1949.

In developing a general pattern for clinical services for children, we believe it is important to define the various kinds of problems, the settings in which they arise, and the differentiated kinds of therapeutic service which they require. I t is also important to see clearly the way in which clinical services are related on the one hand to broad social service programs, and on the other to more specific medical programs oriented to the treatment of illness.

We see the need for three basic types of psychiatric clinics for children: 1. A child guidance service in the schools, primarily focused on mental

health problems of the child in the school-problems of learning and those growing out of the relationship between the child and teacher and between the child and members of his group. The development of these services would be the responsibility of the educational authorities.

2. A child and family guidance service which would be primarily focused


on prevention. Such clinics should also carry some therapeutic function as an aid in training and research. The major responsibility of this kind of service would be the psychological and psychiatric study of children, counsel- ing of parents, work with health and other agencies serving preschool groups, and integration of mental health concepts in the training of other child- serving professions. We recommended that a t the state level, responsibility for the establishment of this kind of service should rest with the Ministry of Welfare, but the actual administration and financing might be carried by municipal welfare departments or voluntary agencies.

3. A medically related child treatment service which would provide for both adults and children and would give special attention to psychosomatic problems and psychological problems associated with organic disease, as well as to various'forms of psychoneuroses and other deep disturbances in the psychological area. The initiative for the development of this kind of service, as well as its administration, would rest primarily with the Ministry of Health.

More fundamental than clinical facilities is the limited supply of qualified social workers, as well as of those in the more specific mental health categories, and the limited degree of competence in social casework and clinical skills which now exist.

Professional Personnel. Although no accurate census exists, it is estimated that professional personnel for the social work and mental health fields in- cludes about 35 psychiatrists, a smaller number of psychologists and anaiyt- ically trained therapists, about 12 psychiatric social workers and about 400 general social workers. Many important positions are unfilled for lack of qualified applicants and most of the government as well as the voluntary agencies are understaffed. Furthermore, workers to fill positions of leadership, supervision and teaching in social work, as well as those with special training, such as psychiatrists, psychiatric social workers and group workers, are perhaps even more greatly needed than general social work practitioners.

Much of the practice in the field of social work and mental health reflects European training and professional methods. While there is keen intellectual interest in the best social work methods and a considerable degree of knowledge of basic concepts in the mental health and social work fields, in the main, the technical skill to integrate these concepts into working procedures is lacking. An outstanding limitation which characterizes professional service is the inadequate grasp of the interrelationship between social and psychological factors both in etiology and treatment. The dynamic inter- play of these two aspects of human problems needs to be more fully under- stood by many of the practitioners.

A plan for raising of standards and increasing the supply of social work personnel must include a number of different approaches and lines of action.

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These include : 1. Establishment of basic formal training programs for the preparation of

social caseworkers and group workers. 2. Formal training programs for the more specialized child-helping per-

sonnel, such as members of mental health teams-child psychiatrists, psychologists and psychiatric social workers. Closely linked to the above is the need continually to evaluate and adapt the training programs and curricula of the related professions involved in child-rearing and child-helping services, i.e., madrichim, teachers, nurses and doctors. Their training should provide sufficient emphasis on understanding of the social and psychological needs of children, so that they may effectively deal with these needs as they present themselves in their specialized practice.

3. Study of the present status of the social worker as a professional and a wage earner. The kind of people who will enter and remain in the field de- pends on the kind of working conditions which exist, including compensation as well as the more intangible professional rewards. 4. The lifting of the general level of practice in existing social service

agencies and departments through the fuller use of the professional personnel available, which would be promoted by in service training, better distribu- tion and strategic assignment, so that the quality of supervision and practice may be raised to the highest possible level within present limitations.

Our recommendations cover the reorganization of the School of Social Work from a technical to a professional level. This step involves higher admission requirements, greater emphasis on practice in the curriculum, an improved faculty and affiliation with the university.

We made one other major recommendation which is designed to meet the need for adequately qualified leadership and teaching personnel, as well as for certain categories of specialized workers in the child welfare field, such as psychiatrists, psychiatric social workers and group workers. We felt that unless a special effort were made to add to the number of workers qualified to fill such positions by bringing qualified people from abroad or by training them in Israel, the development of social work programs for families and children would be seriously delayed. We visualize that this need could be met through the establishment of an Institute on Human Relations which would be affiliated with the faculties of Medicine and Education, the School of Social Work and certain government departments.

The basic responsibilities of the Institute would be: 1) to train leadership personnel for social work and child welfare; 2) to train specialized personnel for the mental health field-social psychiatrists, psychiatric social workers, etc.; 3) to formulate the content of training in mental hygiene of the other child-helping professions, such as teachers, nurses, doctors and madrichim; 4) to carry on research in human relations.


Training Abroad. For some time to come, training abroad will have to be relied upon as one method for increasing the number of qualified professional workers in Israel. We feel, however, that more careful planning is needed if this method is to be of significant help. Planning both in Israel and abroad is needed to determine whether candidates would benefit from the training they hope to take and also to make sure that such training bears a consistent relationship to their qualifications, competence and future professional plans. There are other limitations in this form of training which spring from differences in the level of practice in Israel and in the agencies in which candidates receive their training abroad. There are also losses flowing from the need to readapt professional knowledge and skill to a different professional setting or a different cultural or social structure.

Basic Considerations in Planning. We have tried to sketch briefly some aspects of the social-psychological milieu in Israel and to show how it is composed of elements which stem from the historic past and from present necessities. We have also attempted to show how some of the ideological and reality factors are expressed in the child-rearing pattern of the kibbutz and in the care and treatment of children with special problems.

Space does not permit more than the briefest kind of suggestion as to how planning in Israel might be related to its special problems, needs and conditions. We have seen that Israel perhaps more than most nations knows what it wants for its children and is moving more directly to shape its educational and child-care programs in accordance with its ideals. But we have also seen that social purposes spring from many roots and reflect many pressures and motivations far removed from mental health values. If we were able to make a completely fresh start in planning, we would want to make sure that general social ideals, social structure and patterns of child rearing are consistent with one another and with mental health objectives.

Although the kind of evaluation suggested is beyond our present capacity or resources we might be able to undertake more limited kinds of investiga- tion. An example of this kind of project would be research in the possibility of the group as a medium of education and child care. An objec- tive appraisal of the effect of this method on the personalities of children would be of great value for planning in Israel as well as for the child welfare field everywhere.

Another kind of inquiry which would be valuable a t this time would be one which tried to account for the apparent degree of social and mental well- being which exists in Israel and which seems to contradict the extreme psychological and social hardships to which the population has been and is exposed. How far has the prevailing personal and social idealism either masked psychological symptoms or afforded so much support that people are able to function with relative adequacy?

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Planning should include not only the clarification and evaluation of social purpose, structure and value, but also an appraisal of certain theoretical concepts to see how far they are valid for the special social conditions which exist in Israel. Many of our working concepts in the field of mental health have emerged out of certain kinds of human experience in particular kinds of society, and they may not be equally valid for human relationships in a different social setting. Thus, we assume that all children experience some conflict in loyalty as between one parent and the other, but the character and expression of this conflict may be different in a society in which the parents’ relationship to the child is differently expressed, for example, in the family in a Western European urban community and in the agricultural settlements in Israel.

Closely related to research is the planning process itself. In Israel where change is so rapid, there is danger that improvisation or compromises dic- tated by emergency pressures will take the place of planning. The diversity of cultural and ideological strains makes agreement about basic purposes and values harder to achieve, but for that reason much more important and valuable as an end in itself. The process through which common purposes are achieved is not the exclusive responsibility of planning agencies but needs to be carried on through all formal and informal media and methods which help shape public attitudes and opinions.

indications for mental health planning for children in israel

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