Culture-sensitive therapy and salutogenesis: Treating Israeli Bedouin of the Negev

Abstract

The Salutogenesis theory and its essential component, the sense of coherence (SOC) is an epigenetic concept. The SOC was defined as a ‘way of being in the world’. As such it is most important that one's SOC will be intact for healthy mental status. Collisions between western and non-western cultures might interfere in the process of psychiatric and psychotherapeutic treatment. This review demonstrates the importance of a culture-sensitive approach and therapy and the usefulness of specific culture-sensitive services for certain non-western populations. We illustrate this approach by giving the example of the unique ways of treatment carried out among the Bedouin of the Negev region of Israel.

Introduction

In this paper we would like to demonstrate the importance of promoting health, in light of the salutogenesis theory among non-western cultures. This is possible only when personal and community sense of coherence (SOC) are intact.

Aaron Antonovsky asked a very naïve and fundamental question: from where do human beings get the power to remain relatively healthy (Antonovsky et al., 1971)? His first answer was based on the concept ‘hardiness’, a personality trait which contains three components: (1) The ability to control one's feelings, (2) The conviction, that one has obligations in one's life, (3) The ability or readiness to perceive changes as challenge (Maoz, 2004). Later he phrased his own concept ‘salutogenesis’, and after profound sociological research, he founded the concept of ‘sense of coherence’, as one of the major components of this theory (Antonovsky, 1987; Becker et al., 2010; Lindstrom & Eriksson, 2005). Further research showed that the SOC is statistically responsible for about 21% of the probability to remain healthy. The SOC was primarily defined as a ‘way of being in the world’, which is composed of three components: (1) Comprehensibility, understanding the situation structure, rules in which one lives, (2) Manageability, being able to influence, to control and lead actively the situation in which one lives, (3) Meaningfulness, there are values in life in which one believes and is ready to fight for. A combination of these three factors forms together the SOC. A strong and flexible SOC is a component of the prognosis to remain healthy. Primarily Antonovsky dealt with the SOC of individuals, later also with the SOC of a family and a group. SOC was interpreted in many ways. Values, such as trust (e.g. self confidence; there are others to rely on and there are values and principles that one believes in) and harmony were often emphasized. For example, Theodor Petzold translated the concept ‘sense of coherence’ into German by Stimmigkeit, which means a certain kind of harmony (verbally: a mood in which one is tuned to) (Lamprecht & Gunkel, 2004; Petzold, 2010). ‘What exactly is “Stimmigkeit”? Stimmigkeit is a sensation of harmonizing, in which one has a feeling of well-being, which is continuously kept or in an ongoing process of construction’ (Petzold, 2010, Petzold, p. 32). We experience it, for example, at the encounter of a baby who smiles for the first time with the mother. Others interpreted the SOC as the ability to mobilize (internal and external) resources.

The question whether SOC can be evolved, modulated or empowered was raised from the beginning of the theory. Antonovsky was rather pessimistic but later publication in the area implicated that at least some of the SOC components may be modulated through psychotherapy (Sack & Lamprecht, 1994). There are very few publications about the SOC among people of other, non-western cultures (Braun-Lewensohn & Sagy, 2010; Cederblad et al., 2003).

How can we mobilize resources and strengthen the SOC in such cultures? Our assumption is that an important resource that could be mobilized is ‘culture-sensitive therapy’. This means trying to understand the (verbal and non-verbal) language of patients, trying to learn the cultural anthropological background of patients and to respect their ‘being different’. Accepting and respecting generally the religious-folkloristic healing methods that might exist in the culture of the patient. This whole attitude may prevent dissonances and inter-cultural conflicts, thus making a stimulation of ‘harmony’ possible. Culture-sensitive therapy may thus be a salutogenic resource.

We would like to demonstrate and to discuss in depth this kind of culture-sensitive approach among Arab Bedouin living the in Negev desert in Israel. In addition to some basic data that we are able to present, our description will be based on clinical case reports, the anthropological literature and our own observations based on clinical work with this population during the last 30 years.

Bedouin of the Negev

Bedouin (literally: dwellers of the desert) live in the Negev desert (southern part of Israel). They have three historical roots: (1) Arab tribes who migrated during many centuries from the Arab peninsula to the Negev, (2) people who had once been small farmers in the Negev area (Fellaheen/peasants), (3) people who migrated to the Negev from northern Africa (e.g. as slaves). At the present time the number of Bedouin in the Negev desert is estimated to be over 160,000 (CBS, 2008). They used to be nomads with flocks of sheep, goats and camels, who customarily lived in big tents and wore traditional specific clothes.

During the last 50–60 years many Bedouin settled down in ‘villages’ or small towns, which are partly recognized officially as townships, and partly are ‘illegal’. Most of them work in the Jewish villages and cities of the area and travel by cars and not by camels. They are Israeli citizens, who have all the rights of education, social security, health insurance, etc. Their native tongue is Arabic, and although the main language in Israel is Hebrew, many Bedouin of the older generation, as well as many women do not speak any Hebrew.

The main sociological characteristics of the Bedouin society are the following: It is a tribal, patriarchal society, generally religious (Muslim). Polygamy, although not legal in Israel, is still the custom, especially in the older generation, who find bypassing ways (via religious services) to marry several women. Most marriages are still arranged by the parents, often against the wishes of their children.

As a result of the national social security system and the relatively reasonable economic situation, they have a large number of children. Often one husband and all his wives have more than ten children together.

Women are still discriminated against and live mostly separated from men. Their main task is to give birth to children, especially sons, who are valued much more than daughters. Some women also work in the fields around the nearby Jewish cities (Cwikel & Barak, 2002). According to Israeli law, all boys and girls get compulsory elementary school education and some of them continue to secondary schools and even to universities.

So, by and large this society can be classified as traditional (compared to modern), but it is going through a transitory process of western civilization. Bedouin get the services included in the Israeli national health insurance; and the big public health and primary medicine services have community health centres in the main Bedouin townships. Reach out stationary mental health services are provided by a psychiatric department, which is located in the regional general hospital. There, we tried to develop for this population a special, culture-sensitive service (CSC).

The anthropological–cultural background of Bedouin and its implications in the doctor–patient encounter

The first and immediate problem is that of language and communication. Bedouin patients are treated by psychiatrists, psychologists, psychiatric social workers and nurses who usually do not speak Arabic, while many Bedouin speak only very little Hebrew. Some of these doctors and therapists are themselves relatively new immigrants in Israel, and Hebrew is not their native tongue either. So there is an enormous language and communication and mental challenge involved in this interaction.

One of the ways to deal with this situation is to find an interpreter. This might be an accompanying family member who speaks Hebrew, or one of the non-professional staff of the department. One can imagine how difficult it could be to ask more intimate questions in such a situation and how difficult it may be to get an accurate description of the patient's complaints and symptoms.

Over the years it became obvious that without understanding the language of the patient, doctors (and other therapists) often misinterpret complaints and symptoms of the patient as a psychosis to be treated pharmacologically, while the true problem may have been, for example, a relational-family problem that was manifested in a cultural way. In some cases, the interpreter should not be a translator only, but also a kind of ‘recommender’ (or ‘agent’) who explains the culture of the doctor to the patient, and vice versa (Iglesias, 2010; Valero-Garcés, 2010).

Fortunately, during the last 10 years we have been able gradually to recruit mental health professionals whose native tongue is Arabic (though some are not Bedouin themselves), and we established a culture-sensitive clinic (CSC) for Bedouin (see below).

A second basic issue is the perception of diseases in the Bedouin culture. Diseases are usually perceived as something that ‘fell on a person’ (or hits a person) from outside. It may be a punishment for a committed sin, or it may be just a fatalistic event with no explanation. It comes from Allah.

In professional (behavioural) terms we speak about an external locus of control. In psychodynamic terms one used to speak about an externalized and projected superego.

Therefore a disease can be expelled or driven away by a powerful expert; either a medical or psychological professional or a folkloristic-religious healer, and in terms of culture-sensitive clinic, by both. Bedouin do visit their general practitioner and various medical specialists; but also the parallel folkloristic-religious healing system.

This folkloristic-religious healing system is practised by dervishes. Dervishes have a very long and old tradition of healing. One can find their origin in Sufism, a mystical Muslim movement. Dervish healers, men and women, have studied many years with an elder dervish, who chose them as his/her favourite pupil. They often specialize in certain areas, such as the use of plants and natural remedies, writing amulets, or using music and prayers up to the development of a trance, in which they try to expel actively and intensively the bad ghost which had entered the body of the ill person. They are not paid, but one should give them a gift or food, for their treatment (Al-Krenawi et al., 1996). The healing process of dervishes is based on the general belief, existing among many Bedouin, in evil ghosts or demons. These ghosts may enter a body, penetrate into the body and possess it, so that it is difficult to drive them away. They may also just have ‘flight over the person’ and therefore can be expelled relatively easily. The ‘diagnosis’ of the dervish and the labelling of a certain disorder could be very important also for the modern physician or therapist who treats the same patient, as one may learn a lot from the way the dervish perceived the complaints. Usually the two systems do not clash one with the other. Therefore a culture-sensitive therapist can respect the work of the dervish and relate to it with empathy. As we mentioned already, this, usually indirect, coordination between the physician and the healer might be a very salutogenic resource for the recovery and well-being of the patient(Al-Krenawi & Graham, 2000). It is often possible to ‘translate’ dramatic, e.g. somatic, symptoms and fears of ghosts into well-known psychological and interpersonal problems and to treat them.

A third issue is the culturally adapted methods of psychotherapy that can be used successfully. Bedouin patients are usually not highly psychologically minded; this makes the application of psychodynamic methods very difficult. They think rather in terms of interpersonal relations and schema and are usually easily influenced by suggestions.

Therefore we developed a method of brief strategic interventions in the family (meeting all family members during home visits). Such an intervention may change difficult interpersonal relations in the family dramatically. Interventions must be prepared carefully; one should not ‘shoot in the dark’. So, before making such an intervention, one has to learn carefully the ‘map of relationships’ in the family; to find out who is the strong and real leader of it and to try to establish a coalition with this person. Officially, the father is seen as the leader of the family, but often the mother is the real and more powerful leader behind the curtain. One should have a clear and definite goal: what do we want to change in this family? The high prestige usually given by Bedouin to doctors can be used. Such an intervention could preferably be carried out during home visits. This approach is perhaps strange for a modern western and democratic therapist, but it suits the basically hierarchic, paternalistic characteristics of the Bedouin culture(Al-Krenawi et al., 1994).

As it was not possible to make many home visits in the Bedouin community, which is geographically spread over the whole Negev, we adapted these treatment methods to the needs of this population in our a.m. CSC.

The culture-sensitive clinic

As stated above, the gap between western norm, mentality and culture and the Bedouin culture constitutes a challenge to the mental health provider. The therapist must be familiar with the beliefs that characterize this population, as well as the familial patterns and the terms they use for describing their symptoms. In many cases, when Bedouin patients claimed that demons had possessed them, they were diagnosed as suffering from psychosis, even though they meant to say that they were anxious.

But of course there are also ‘real’ psychotic patients. Family therapy, for example, has proven beneficial in cases such as schizophrenia, depression and PTSD. In the patriarchal Bedouin family however, it is highly unacceptable to expose the weakness of the father or to lessen the father's importance since it may harm the entire family sense of coherence. Hence, family therapy had to be modified to suit the Bedouin family structure.

After many years when we had not enough Arab speaking therapists, the situation improved and at the present time the CSC unit consists of three psychiatrists, of which two are native Arabic speakers (not Bedouin though). Also there are two social workers including an Arabic speaker. The CSC staff are familiar with the customs, culture and religion of the Bedouin, and most importantly they are familiar with the traditional healers in such a way that enables indirect collaboration in treating patients. During the past 20 years the CSC managed to bridge the stigma of the Bedouin population towards mental health. During recent years the CSC has an average of 1000 Bedouin contacts per year. A study that examined the referrals of Bedouin to CSC found that 40% of patients had diagnoses of the psychotic spectrum during 1990, while only 12.5% were diagnosed as such during 2004–2007(Shalev et al., 2007). This is mainly due to understanding cultural background. Another finding of the study was that during the last 8 years 48% of the patients were female while they were less than 10% of Bedouin patients 15 years ago. Furthermore, understanding the mentality and the ability to intervene without diminishing the coherence of the individual and the family yielded opportunity for women to present difficulties such as being second or third wife. Indeed, 8.5% of the patients during 2004–2007 had diagnoses of adjustment disorder, a diagnosis that was not diagnosed almost at all during the 1990s when women applied for treatment only in cases of psychosis or severe depression.

Due to low compliance rates for long-term therapies, the sessions have been modified to suit the specific needs. Most of the sessions are in the presence of both psychiatrist and social worker. The duration of the sessions is up to 90 minutes and a great effort is made towards one-session therapies. Aside from individual therapy, any other interventions are held within the family (see the clinical example below). Incursion of an external instructor, as part of a rehabilitation programme, is highly unacceptable and the CSC staff instructs a family member as an instructor for the identified patient.

A clinical example illustrating some of the a.m. ideas

A young 22-year-old Bedouin man was referred to our mental health clinic with dramatic psychotic symptoms. He had visual hallucinations in which a group of old men, with white beards, came and called him to join them in the ‘world of death’. He suffered from extreme anxiety. He was initially diagnosed as psychotic and treated by anti-psychotic drugs.

At that time we had the opportunity to work with a Bedouin social worker, who was asked to listen to the detailed narrative of this suffering young man. Slowly, this intensive listening developed into psychotherapeutic sessions. The following story emerged.

The young man had been extremely angry with his mother and even cursed her. (Blessings and curses have an enormous power in this culture). The old men who appeared repeatedly in his fantasy (there were no real visual hallucinations) wanted to punish and to kill him, as according to Muslim law and tradition, cursing one's mother is a terrible sin. The therapist arranged a family meeting including the son (the patient) and the mother. He did that, after learning carefully the ‘map’ of the relationships in that family and after making acquaintance with the mother and the oldest brother (the mother was a widow), by making a home visit and showing them the required respect.

Before this important family meeting the therapist had some individual therapeutic sessions with the patient, using mainly Gestalt techniques: speaking to the mother in an empty chair for example, asking the patient to sit in the chair of the mother and ‘playing’ her, etc.

Finally, reconciliation between mother and son occurred, and the semi-psychotic symptoms almost disappeared. But something was missing and therefore the patient did not recover completely.

He wanted to be treated also by a dervish, because he believed that only a dervish can deal with the relationship between a human being and God. The mother had forgiven him, but God not yet!

So, the dervish treated him too, and found that he was possessed by a bad ghost who had penetrated into his body. He mainly treated him by beating his body heavily, in order to expel the ghost. Beating, together with prayers, music and singing till going into ecstasies, was effective and the ghost disappeared.

It is clear that the patient perceived that dealing with the relationship between mother and son (and the whole family) is the task of medical or psychological therapists, but the ‘theological’ aspect was seen as out of their realm, and therefore as a problem to be treated by a dervish.

We would like to emphasize again the following point: one should not only be aware of such cultural processes (including religious-folkloristic healing), one should not only tolerate them, or allow them (as long as they do not disturb severely our scientific treatment), but one should even respect them. The patient must get the feeling that the doctors (or the therapists) have no objection at all, that in addition to their treatment he is treated also by a dervish; he knows that his doctors might even be interested and curious about the way the dervish perceived the problem, how he labelled it and what he decided to do.

Conclusion

The main goal of this review article was to demonstrate the importance of the application of culture-sensitive therapies for the promotion of health among the Negev's Bedouin.

One has to overcome as far as possible the language barrier, which always exists in an encounter between patients and physicians (and other therapists) belonging to different cultures. Sometimes a medical translator must be involved, with all the problems of such a step. In other cases the service is able to recruit Arab speaking mental health professionals and to establish a culture-sensitive clinic.

Doctors and other therapists may have an open ear for the anthropological–cultural background of these patients, for their general perception of diseases and for the special cultural way in which diseases and life problems may be manifested. With some basic anthropological training, it is often possible to convert a mystical–magical manifestation, gently and respectfully, into a ‘normal’ and well-known personal or interpersonal problem. Such a problem may then be treated with psychotherapeutical methods suitable to the culture of the patient and his/her family.

One should take into account that many Bedouin patients treated in a mental health clinic (including a special CSC), may turn in parallel to the religious-folkloristic healing system of dervishes. The authors learned to respect the tradition of dervishes and even became curious to learn more about their way of work. This is important for many patients: patients can speak with their doctor (or therapist) openly about their experiences with the dervish. They do not have to hide their visits to the dervish, they do not have to lie or to be ashamed.

According to our experience, official mental professionals almost never meet a dervish personally, but there is (or should be) always an indirect contact between the two authorities. Such a ‘harmony’ between two such different systems, and such coordination, should be an important salutogenic resource for the well-being of Bedouin patients.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.