Staying normal in an abnormal corner of the world: mental health counseling in Israel.

In the course of the last four years, Israeli citizens have repeatedly been exposed to terrorist attacks, and there are several other issues in Israel's current situation that highlight the need for intensive mental health counseling. The article focuses on Israeli school counselors and describes some of the problems they were obliged to face in order to help schoolchildren, their families, or the entire school system stay normal in an abnormal situation. These issues include: death and mourning, social cohesion as a risk factor, immigrants' maladjustment, unemployment, intercultural conflicts, and spiritual debates. Implications for mental health counseling are offered.

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People are amazed when they realize that the entire land area of the State of Israel is smaller than Yosemite Park and that the total number of its residents is smaller than the number of those living in the city of New York. Their amazement stems from the gap between these numbers and the prominent presence of Israel in the world news, especially in the course of the last four years, since the outbreak of another cycle of bloody armed conflict between Israel and the Palestinians. Moreover, Israel's name is frequently mentioned in the context of several major recent developments in the world. The U.S. military operation in Iraq is one of these. Although Iraq is far away from Israel, before the U.S. troops' invasion of Iraq, Israel's citizens were trained how to use a gas mask in case of an Iraqi chemical attack on Israel. The reason for these preparations was the 1991 Gulf War, when U.S. troops invaded Iraq, and the Iraqis attacked Israel's civilian population in response. Although Israel had no part in that military operation, about 40 Iraqi Scud missiles hit some of its crowded urban civilian centers.

Some of Israel's unique characteristics (e.g., an immigrant society, in which Jews and Muslims coexist; being surrounded by hostile countries; compulsory military service for every Jewish male and female adolescent; very meager natural resources; and an extremely condensed geographical area) and their implications for counseling school and university students have been described (Israelashvili, 1993, 1996). The current article focuses on issues related to mental health counseling that Israeli school counselors had to address in the course of the last four years, since the outbreak of the most recent Israeli-Palestinian armed conflict in September 2000, known as the Al Aqsa Intifada.

According to the Board of Directors of the American Mental Health Counselors Association (cited in Palmo, 1996), mental health counseling deals with the provision of professional counseling services for the purposes of prevention of mental and emotional disorders and promotion of optimal mental health. In Israel, mental health counseling is not a certified profession. Nevertheless, most Israeli school counselors have recently faced the challenge of providing mental health counseling to prevent illness and dysfunctional behavior. This is due to the stream of events and threats that many Israeli school children have recently been intensively exposed to as described below.

A NEED FOR MENTAL HEALTH COUNSELING IN ISRAELI SCHOOLS

A differential approach is needed when working with children of various ages. Regardless of age, exposure to certain types of events poses a threat to anyone s mental health. Recently, many Israeli school children have been intensively exposed to one kind of extremely threatening event, namely terrorist attacks.

Since the establishment of the State of Israel in 1948, and even before, its residents have often been exposed to terrorism. But the incidence of such attacks increased dramatically following the 1973 Yom Kippur War, following the failure of a coordinated attempt of Arab nations to defeat Israel. Another sharp increase in terrorist attacks against Israeli citizens started in 1993, following the Israeli-Palestinian agreement also called the Oslo accords; this increased terrorist activity has not abated. Four features characterize the last wave of attacks: (a) Attacks are frequently conducted by a suicide bomber, who explodes him or herself within a crowd of Israelis; (b) No Israeli is really safe against such a suicidal bomber because attacks have been conducted almost everywhere in Israel, not only along the borders or against the settlements within the contested occupied territories, killing and wounding people of all ages, especially Jews but also some Israeli Muslims and Christians; (c) Usually, the Israeli army (IDF) conducts reprisals on the terrorist organization that claims responsibility for the attack; and in addition (d) In an effort to prevent future attacks, the IDF conducts various military operations from time to time, such as the assassination of terrorist leaders. In both cases, of reprisals and assassinations, innocent Palestinian civilians may be wounded or killed. Thus, terrorist attacks cause damage not only to Israeli civilians but also to Palestinian civilians as well. Moreover, damage caused by terrorist attacks is not limited to those who have been in the area where the attack occurred. Rather, the media instantly brings any event to the houses of all. Israeli media coverage of each event is highly extensive, with repeated displays of bloody footage, including dead bodies, destroyed cars, people crying, etc. As a result, in the current wave of terror attacks, the cycle of direct or indirect exposure is much more protracted than it used to be.

Generally speaking, research has indicated that exposure to a terrorist attack is frightening but does not always lead to major mental health problems. Several indicators show that the Israeli population is resilient and adjusts well to war-related emergencies (Bleich, Gelkopf, & Solomon, 2003). Nevertheless, in such circumstances of protracted threat and violence, school systems are expected to continue functioning in spite of the stress, and to offer mental health services to the children and through them to their families (Milgram, 1993). School counselors, who usually focus on the promotion of students' wellness, are in charge of these services (Noam & Hermann, 2002; Shen & Sink, 2002). The mental health issues that Israeli school counselors are obliged to deal with include mourning, social cohesion issues, effects of unemployment, inter-cultural conflicts, and spiritual debates

MOURNING

Approximately 1,000 Israeli citizens have been killed in terrorist attacks since the 1993 Oslo agreement (IDF Spokesman, 2004). Unfortunately, school-aged children were killed, others lost their parents or relatives, and for some it was "that nice neighbor from next door." In addition, thousands of others who were exposed to these attacks were damaged, physically or psychologically. In the case of a terrorist attack, an estimated 10% to 20% of school students might be in need of help (Chen, Chung, Chen, Fang, & Chen, 2003; Israelashvili, 1999). It is plausible to assume that the rate of Palestinian school children that are in need of help following a violent attack is similar. Unfortunately, in the West Bank and Gaza there are neither data about the scope of the need for mental health services among schoolchildren nor a significant amount of counselors or psychologists who work within the school settings. Several students found support and comfort within their families and social networks. Yet, many are in need of professional support in order to adjust (i.e., internalize the loss of their beloved and face the future). Hence, many counselors found themselves confronted with the need to conduct an intervention that discussed issues of death and mourning.

On one occasion, an Israeli school counselor was asked to talk with one of the children in her charge whose mother was murdered by a terrorist. While talking to this 10-year-old, the counselor uncovered a family secret about the father, who had been seriously injured in a previous terrorist attack several months ago, and, unlike what everybody thought, was still unable to manage his life independently. In an attempt to debrief the child, the counselor asked him to draw a picture of his feelings. The pictures, made in red and black colors, represented a child who wished to join his mother, who "left him by himself to help the father recover." It was evident that the child felt completely lost in his new situation. The counselor was afraid that the child might do something suicidal to join his mother. To prevent this, the counselor thought of three possible channels of help-giving: counseling the child himself, counseling the father on how to support his child, and consulting with the child's class teacher on ways to follow and support the child inside and outside the class. Clearly what was needed was a comprehensive effort, on all these channels, so as to minimize the risk. The only problem was the counselor's commitment to the other 200 schoolchildren, for whose various normal-developmental problems she was supposed to be catering.

Hence, for some school counselors, the problem also becomes a quantitative one: How to give the most appropriate attention to a child at urgent risk, while so many others also require support? This dilemma especially emerges among counselors working in areas suffering from repeated terrorist attacks, such as the city of Jerusalem. Below are some examples of the problems that Israeli school counselors have encountered in the last few years in pursuit of their schoolchildren's mental health.

HANDLING MATTERS OF SOCIAL COHESION

Beyond the person who had been directly hurt by a terrorist attack, there are other people who are less directly involved but nevertheless are affected by the same event. One example is peers' response to the death of one of their classmate's relatives. The following example is only one out of many cases.

M., a ninth grader, was a leading figure in her class. She was loved and admired by many for her vividness and positive character. M's mother was murdered by a terrorist while she was driving on the highway from her work back home. This event came as a great shock to the school, but especially to her classmates. A few days later some of the class students asked for the counselor's help in guiding them on how to manage their relationships with M. Several more students asked for the school counselor's help, because they suffered from "worries about the safety of their own family members." It also gradually appeared that the whole class was troubled by M.'s silence; she would sit in the class for hours without saying anything. Teachers were complaining that instead of listening to them, the whole class was closely watching M. "Do we see a tear in her eye?" "Was she moving restlessly in her chair?" "Did the class discussion have any relevance to M.'s life?" The situation became even more complicated when M. finally shared her feelings with the class, reporting that she felt unable to go back into her empty home: "I go back home, enter the house, and then suddenly I realize my mother is not there ... she will never be there ... and it hurts me again and again, whenever I enter my home."

Furthermore, M. was wondering how she should respond to her father's new expectations of her as the one who would be in charge of their daily living. One of M's major concerns was that she felt badly about the fact that "the whole school" was aware of her sorrow. In spite of many people's efforts to prevent it, several months later, M. made up her mind to leave for a residential school, far away from home and her previous school. The whole class felt that it was their fault, having been unable to help her overcome the tragedy and readjust to the new circumstances.

Following M.'s mother's assassination, the academic achievements of the entire class dropped significantly. However, from the resilience and mental health point of view, the major problem was that the ultimate cohesion of this class, usually considered as a protective factor, came to be at risk. The school counselor's main task was to conduct a group intervention that would foster social cohesion by supporting students' differentiation between their own well-being and their loyalty and care to M.

Although not of the same importance as other aspects of M's situation, another source of strain for M and her remaining family members was the major economic problem that they all had to face due to the passing away of one of the family providers. This is not unique to M's case; indirectly, Israel's security problems brought about widespread economic hardship and unemployment to many individuals and families who, in response, look for mental health counseling.

UNEMPLOYMENT

The Israeli-Palestinian armed conflict has a major impact on the economic situation, both in Israel and the Palestinian Authority. For example, tourism, known to be one of Israel's major financial resources, has almost totally stopped. In addition, in order to prevent terrorist attacks, Palestinian workers have not been allowed to work within most of Israel. Unfortunately, these conflict-related problems were compounded by the crisis on the international technology market that had major negative financial impact on hi-tech companies around the world. The Israel economy is profoundly implicated in the world's hi-tech activity and has, as a consequence, suffered from another drastic reduction in its financial status. For many adults, the hi-tech crisis and the resulting unemployment brought great psychological strain; for many adolescents, it spelled the end of long-term vocational plans, while, more immediately, it constituted a source of conflict between them and their unemployed or financially strained parents.

Occupationally, counselors sometimes find themselves addressing mental health issues that emerge in the course of a discussion on vocational issues (Pace & Quinn, 2000), such as a complaint about the lack of meaning and goals in life. School counselors, similarly, have had to address schoolchildren's problem behavior initiated by parents' unemployment. One of the questions that an unemployed person (and his or her children) may ask oneself would be--why not immigrate to another state? What actually attaches me to this society? These questions become crucial once the person realizes that there are not any clear-cut answers to them.

INTERCULTURAL CONFLICTS

Several factors shape the intercultural make-up of Israeli society. One of them is the mix of religions--Jews, Christians, Muslims, and Druze; within each of them, there are people with various levels of religious practice (i.e., ultra-orthodox, orthodox, and secular). Add to this the many cultural differences between Jews who immigrated to Israel from European or American countries and those who immigrated from Africa and Asia. Multiply this by a wide span of political perceptions related to issues in the Middle East. And, finally, triple this again by significant differences between residents in urban vs. rural vs. kibbutzim areas. It is evident that Israel is characterized by a rich mosaic of ethnicity and religions, which inevitably can be a source of inter-cultural conflict. One aspect of the differences of opinions within Israeli society is Jewish Israeli and Palestinian Israeli school counselors' opinions regarding the political situation in Israel (Tatar & Horenczyk, 2003). According to Tatar and Horenczyk, Arab counselors conceptualize the conflict as a minority struggle to attain equality, while the Israeli Jewish counselors perceive the conflict in terms of the survival struggle of Jews in the face of a threatening Arab world.

Occasionally, differences in opinions held by members of various segments of Israeli society (e.g., Jews vs. Muslims; new immigrants from the former USSR vs. new immigrants from Ethiopia; ultra-orthodox Jews and Muslims vs. secular Jews and Muslims, respectively; and others) might lead to acts of mutual aggression. Hence, many school counselors are called on to conduct conflict resolution workshops, in an attempt to reduce violence and antisocial behavior. In those inter-cultural conflicts where debates may spill into physical or verbal expressions of aggression, school counselors are obliged to ignore their own political and social views and help schoolchildren overcome the traumatic event they have just been involved in. To some counselors, abandonment of their own personal attitudes and opinions is not that easy to conduct, as sometimes that conflict is highly related to their own beliefs and may be even part of their entire spiritual world. Such a subjective feeling of pressure to reorganize one's spiritual world, initiated by external events, is even more frequent among the conflicting children themselves.

SPIRITUAL DEBATES

Because of being unable to ignore the terrifying pictures on television and almost everywhere else in their surroundings, Israeli and Palestinian adolescents face major spiritual questions: "What is good?" "Who is good?" "Is there anyone who is 'good' in this situation?" "What is right?" "Where is God in such horrible occasions?" "Who am I?" These are only a few of the many questions every person, especially an adolescent, will start asking her or himself when living under the conflict conditions that characterize the Middle East. Adults' answers to such questions may often seem unsatisfactory to adolescents. Moreover, adolescents may well realize that most Israeli adults are using denial as a way of survival. According to Terror Management Theory (TMT) (Greenberg, Arndt, Simon, Pyszczynski, & Solomon, 2000), encounter with mortality salience while being unable to use avoidant mechanisms in order to escape from the emotional terror feeling that is adjunct to exposure to death, will lead to greater identification with the norms of the surrounding people. Practically speaking, most schoolchildren will tend to deny the questions mentioned above and they will try to follow their Israeli Jewish, Israeli Arab, or Palestinian class-mates. Nonetheless, sooner or later, some of them will turn to the counselor, asking for help in finding better answers (Jones & Kafetsios, 2002). Can the school counselor really help in finding the answers?

The continuation of the Israeli-Palestinian conflict might bring about more debates and problems for the mental health counselor. Almost each day new phenomena and/or variations of old ones emerge. Nevertheless, in the course of the repeated encounters with these and other issues several general implications for mental health counseling have emerged.

IMPLICATIONS FOR MENTAL HEALTH COUNSELING

Many people would agree that the Middle East is only part of the global scene. Since September 11, 2001, many nations around the world are intensively occupied with efforts to protect themselves from terrorism (Jordan, 2002; Post, 2002). Citizens of these nations are now bothered by daily hassles (e.g., airport security) with which Israelis have been familiar for several years. Thus, most of the problems listed here seem to have become international, rather than being more specifically related to the Israeli experience. To the extent this is the case, some lessons from the Israeli experience might be useful to mental health

counselors worldwide, which are described below.

Support for terror victims as is consistent with the essence of the mental health counseling identity. A terrorist attack, defined as an act of violence against innocent people, is inhumane behavior. Hence, exposure to such an attack will naturally be shocking and may lead to extreme responses. Some of these extreme responses are listed in DSM- IV (American Psychiatric Association, 2000), like social discomfort, lack of close friends (i.e., avoidant personality disorder), and other symptoms listed on Axis 4 or Axis 5. However, due to the general abnormal situation in this corner of the world (i.e., Israel), most of those who suffer from these extreme responses should be regarded as having normal--rather than abnormal--problems. Ellis (1992) suggested a distinction between first-level changes (i.e., helping a person to adaptively change her or his behavior in order to meet a given, new situation's demands) and second-level changes (i.e., changing the person's basic approach to situations in order to help him or her better manage his or her life). In line with this distinction, it is plausible to suggest that the major task many Israeli school counselors faced in the last few years was to help people make a first order level change that was imposed on them by the abnormal situation in this corner of the world. In other terms, this means that they need counseling rather than therapy. Referring to debates among professionals in mental health counseling (e.g., Fong, 1990; Mate & Kelly, 1997; Palmo, 1996), it seems that the intensive and positive experience many Israeli counselors have had during the last four years supports the possibility that the differentiation between mental health counseling and mental health psychotherapy has to do a lot with the normality of the situation, rather than the "normality" of the person's behavior.

Using proactive interventions. In light of the evident need for counseling following a terrorist attack, another general conclusion that can be drawn from the Israeli experience is that mental health counselors' interventions should be proactive in addition to being reactive. Thus, preventive mental health interventions should be initiated, especially at the community level (Granot, 1995), whenever the probability of a large-scale threat increases. In order to do this kind of intervention, mental health services should be established within each community and each school, and preliminary guidance on how and when to intervene should be offered to the relevant staff. This recommendation fits the growing awareness of the need to develop more school-based mental health counseling centers (Bugai & Manning, 2002; Hall & Torres, 2002; Vanderbleek, 2004).

Preferring comprehensive intervention. Following direct or indirect exposure to a traumatic event, counselors' interventions are needed simultaneously at the individual, group, and organizational levels. Many schoolchildren and their teachers are in need of either crisis or post-crisis intervention. The existence of such a need is not always obvious to other adults, such as the school principal or the students' parents. Sometimes adults are not even aware of the school-based support services (Kirkley & Medway, 2003). Once a school counselor is willing and is able to conduct a preventive intervention to minimize mental health problems following an exposure to a traumatic event, this should be done in a comprehensive way (i.e., intervention directed at the school principal and his or her managing team, the school teachers, parents, community representatives and, of course, the children themselves). It should be noted that many of the activities needed in these cases are not unique to terror attacks. Rather, they are very similar to counseling interventions required whenever a school counselor has to intervene in times of a sudden death in schools (Page & Chandler, 1994; Thompson, 1995). However, the problem that the counselor might face in times of a terrorist attack is the work load that stems from the need to intervene among different populations, using different techniques, within a very short period of time. More details about the "how" and "when" of these interventions, drawing on experience in the Israeli school system can be found in Klingman (2002).

Helping the helpers. Members of the school support team (i.e., educational counselor, educational psychologist, teachers of special education, school nurse, and school religious authority if the student is in a religious school) must coordinate their activities in advance and have their own opportunities for guidance, debriefing and mutual support (Seri, Mallach, Lisha, & Libman, 2001). For many school counselors, family support is not enough, as the stories and problems are tough and stress evoking by themselves. The major solution that counselors found was to establish their own professional support group, sometimes on a daily basis, in which discussion of any issue was legitimate. This model of collegial support group, rather than reliance on the natural support group, was offered to teams of school teachers, usually under the guidance of the school counselor.

Advocating the power of counseling. Finally, a belief in the power of counseling should be advocated. A detailed analysis of 10 terrorist attacks taking place in Israel in the course of 1974 to 1975 led Ayalon (1983) to conclude that a lot can and should be done in order to prevent mental health problems among victims of terrorist attacks. There has been much supportive evidence to this effect in the intervening years. Moreover, it was often the school counselor, functioning as a mental health counselor, while incorporating knowledge of normal and developmental issues, who made the difference in helping people survive such abnormal circumstances. By doing so, Israeli counselors, who live and work in this abnormal corner of the world, foster the notion that in the future there will be much more demand for professionals conducting mental health counseling.

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Moshe Israelashvili, Ph.D., is with the School of Education, Tel Aviv University, Tel Aviv, Israel E-mail: [e-mail]