The impact of migration on the The impact of migration on the mental health of the “Beta-mental health of the “Beta-

Israel” (the Ethiopian Jewish Israel” (the Ethiopian Jewish community in Israel).community in Israel).

Anne-Marie Ulman MDAnne-Marie Ulman MDBeer Yaakov Mental Health CenterBeer Yaakov Mental Health Center

Sackler Faculty of Medicine, Tel Aviv UniversitySackler Faculty of Medicine, Tel Aviv University

Centre Georges DevereuxCentre Georges Devereux

Universite Paris 8 Saint-DenisUniversite Paris 8 Saint-Denis

http://www.ethnopsychiatrie.nethttp://www.ethnopsychiatrie.net

““The Beta-IsraelThe Beta-Israel””

The Ethiopian Jewish CommunityThe Ethiopian Jewish Community

in Israelin Israel

Today’s community: 120.000 membersToday’s community: 120.000 members

19841984: “Operation Moses”: “Operation Moses”

19911991: “Operation Solomon” : “Operation Solomon”

Ethiopian-JewishEthiopian-Jewish cultureculture

- Lived in the highland villages in the north-Lived in the highland villages in the north-western regions of Gondar and Tigraywestern regions of Gondar and Tigray

- Tribal cultural model (the Shmaglotch’s law)Tribal cultural model (the Shmaglotch’s law)

- Patriarchal family organizationPatriarchal family organization

- Oral transmission of the traditionOral transmission of the tradition

HistoryHistory

- 1818thth century: James Bruce uncovers the century: James Bruce uncovers the existence of the “falasha”existence of the “falasha”

- Prof. Joseph Halevy (1867):Prof. Joseph Halevy (1867): Establishment in Abyssinia before the Establishment in Abyssinia before the

development of the Talmud as cause of the development of the Talmud as cause of the difference in rites between “Beta-Israel” and difference in rites between “Beta-Israel” and the rest of the Jewish Diasporathe rest of the Jewish Diaspora

- Dr. Jacob Faitlovitch: Prof. Halevy follower, - Dr. Jacob Faitlovitch: Prof. Halevy follower, dedicated to the cause of the Ethiopian Jews, dedicated to the cause of the Ethiopian Jews, promoter of their education promoter of their education

Literature reviewLiterature review

Psychopathology among Psychopathology among Jewish Ethiopians (I)Jewish Ethiopians (I)

Arieli & Aycheh, 1991Arieli & Aycheh, 1991

Two major sources of psychological distress:Two major sources of psychological distress:

- The trauma of the journey:- The trauma of the journey:Comparable to the experience of Holocaust survivorsComparable to the experience of Holocaust survivors

Inability to respect burial traditionInability to respect burial tradition

Guilt feeling toward the family left behind Guilt feeling toward the family left behind

The interface with the Israeli reality:The interface with the Israeli reality:Control of HebrewControl of Hebrew

Economic statusEconomic status

Place of residencePlace of residence

Religious issuesReligious issues

Somatization not yet Somatization not yet understood as an understood as an

expression of expression of psychological distress psychological distress

Arieli & Aycheh, 1991Arieli & Aycheh, 1991

Psychopathology among Jewish Psychopathology among Jewish Ethiopians (II)Ethiopians (II)

Arieli & Aycheh 1991Arieli & Aycheh 1991

37,3% -------------- anxiety 37,3% -------------- anxiety

28,4% -------------- depression 28,4% -------------- depression

29,4 % ------------- somatization29,4 % ------------- somatization

11% ---------------- psychosomatic activity 11% ---------------- psychosomatic activity

28,8% -------------- sleep disturbance, nightmare28,8% -------------- sleep disturbance, nightmare

The “culture shock” was The “culture shock” was directlydirectly responsible for the responsible for the

psychopathology found among the psychopathology found among the “Beta-Israel“Beta-Israel””

““acculturation stressacculturation stress””

the result of the conflict between the result of the conflict between the need to cope with new values of the need to cope with new values of

the host culture and the need to the host culture and the need to stay faithful to traditional cultural stay faithful to traditional cultural

values of reference. values of reference.

The acculturation stress of the The acculturation stress of the Ethiopian community is among the Ethiopian community is among the

highest that any community highest that any community experienced during the immigration experienced during the immigration

process.process.

Arieli & Aycheh 1991Arieli & Aycheh 1991

SomatizationSomatization

- -Bodily expression of an emotion or physical Bodily expression of an emotion or physical illnessillness

- -Difficult encounter with the Israeli medical Difficult encounter with the Israeli medical systemsystem

- -Youngmann (1999): Generalized unlocalized Youngmann (1999): Generalized unlocalized pain and pain localized typically in the head, pain and pain localized typically in the head, heart and stomach are common heart and stomach are common metaphorical somatic complaintsmetaphorical somatic complaints

Other ways of coping with Other ways of coping with distress (I)distress (I)

- Brief reactive psychosis- Brief reactive psychosis

(Grisaru 2003)(Grisaru 2003)

- -Brief psychotic episodes appeared instead of Brief psychotic episodes appeared instead of classical PTSD classical PTSD (Grisaru 2003)(Grisaru 2003)

“ -“ -Eating arrest” Eating arrest” (Gady Ben-Ezer, 1990)(Gady Ben-Ezer, 1990)

- -Dissociative disorders among the Ethiopian Dissociative disorders among the Ethiopian origin adolescents origin adolescents (Ratzoni 1993)(Ratzoni 1993)

Other ways of coping with Other ways of coping with distress (II)distress (II)

- -Adolescents dissociative reaction could be Adolescents dissociative reaction could be connected to the Zar spiritsconnected to the Zar spirits (Ratzoni 1993) (Ratzoni 1993)

1010 to 12% of the patients presented a Zar Spirit to 12% of the patients presented a Zar Spirit link clinical picturelink clinical picture

))Arieli 1994, Grissaru 1997Arieli 1994, Grissaru 1997((

Zar Syndrome:Zar Syndrome:Cultural norm or pathologyCultural norm or pathology??

The Zar SpiritThe Zar Spirit

The Zar Spirit (I)The Zar Spirit (I) Mythology Mythology

(Kahana, Nudelman, Edelstein)(Kahana, Nudelman, Edelstein)

- - Common origin to humans and spirits Common origin to humans and spirits in Garden of Edenin Garden of Eden

- The Zar spirits are the descendants of The Zar spirits are the descendants of Eve’s hidden children who were given Eve’s hidden children who were given the power to possess their human the power to possess their human relativesrelatives

- Parallelism between human and magic Parallelism between human and magic world world

The Zar Spirit (II)The Zar Spirit (II)

- -Zar spirits cause specific physical and mental Zar spirits cause specific physical and mental afflictionsafflictions

- -The mental troubles attributed to the Zar are The mental troubles attributed to the Zar are considered as curable by negotiationconsidered as curable by negotiation

- -Wadaja: monthly gatherings scheduled according Wadaja: monthly gatherings scheduled according to the Ethiopian calendarto the Ethiopian calendar

The Zar Spirit (III)The Zar Spirit (III)

““Once the Zar rides his horse he Once the Zar rides his horse he never gets off his back reallynever gets off his back really ” ”

))Ethiopian proverbEthiopian proverb((

The Zar Spirit (IV)The Zar Spirit (IV)

- -A balazar is someone afflicted by a Zar spiritA balazar is someone afflicted by a Zar spirit

- -Not very Balazar is a Zar-DoctorNot very Balazar is a Zar-Doctor

- -Zar spirits transmitted over 7 generationsZar spirits transmitted over 7 generations

- -Zar-clan: rival structures hierarchy organized Zar-clan: rival structures hierarchy organized (Zar-Doctor, principal adepts, afflicted)(Zar-Doctor, principal adepts, afflicted)

- -Treatment failure are viewed as an admission of Treatment failure are viewed as an admission of human inferiorityhuman inferiority

The Zar Spirit (V)The Zar Spirit (V)

““The Zar afflicted are not The Zar afflicted are not considered gods or even considered gods or even

supernatural, but rather humans supernatural, but rather humans altered by the divine in a mythical altered by the divine in a mythical time. Zar is a way of dealing with time. Zar is a way of dealing with

invisible forces, fortune, invisible forces, fortune, misfortune, illness and well-misfortune, illness and well-

beingbeing ” ” ))Edelstein 2000Edelstein 2000((

The Zar Spirit (VI)The Zar Spirit (VI)

““Zar spirits, as well as the Zar spirits, as well as the Ethiopian Jews with whom they Ethiopian Jews with whom they

immigrated, are still immersed in immigrated, are still immersed in a transition process searching for a transition process searching for their own niche on their way to their own niche on their way to

integration in their new integration in their new homelandhomeland””

))Nudelman, 1995Nudelman, 1995((

The suicide issue (I)The suicide issue (I)(Shoval and al. 2007, (Shoval and al. 2007, Arieli 1996Arieli 1996 ) )

19841984: suicide rate among the “Beta-Israel” : 25:100,000 : suicide rate among the “Beta-Israel” : 25:100,000 (6:100,000 national suicide rate). (6:100,000 national suicide rate).

19861986: suicide rates sevenfold higher among the “Beta-Israel” than : suicide rates sevenfold higher among the “Beta-Israel” than the nativesthe natives

19911991 – 1992: 3 times higher. – 1992: 3 times higher.

The suicide Issue (III): The suicide Issue (III): A survey Conducted by Means of a A survey Conducted by Means of a

Psychological AutopsyPsychological Autopsy(Arieli & al., 1996)(Arieli & al., 1996)

High risk factors:High risk factors:

- Young married man with family - Young married man with family conflictsconflicts

- Internalization of aggression - Internalization of aggression

- Depression- Depression

- No communication of suicidal - No communication of suicidal intentionsintentions

The suicide issue (IV):The suicide issue (IV):How can this phenomenon be How can this phenomenon be

understoodunderstood??

- - Suicide of “Samsonic” natureSuicide of “Samsonic” nature (Arieli 1996)(Arieli 1996)

- - Epidemic wave”Epidemic wave” because of a traumatic transculturation because of a traumatic transculturation process (Durst 1993)process (Durst 1993)

- - Prejudice, discriminationPrejudice, discrimination and consequent social seclusion and consequent social seclusion (Ringer 2005) (Ringer 2005)

- - Cultural misunderstanding by professionalsCultural misunderstanding by professionals: possible cause : possible cause for under-diagnosis and under-treatmentfor under-diagnosis and under-treatment (Shoval 2007)(Shoval 2007)

- - Adolescents suicideAdolescents suicide: result of great stress in combination : result of great stress in combination with the learning of a new “language” from Israeli with the learning of a new “language” from Israeli counterparts. counterparts.

Group Counseling and PsychopathologyGroup Counseling and PsychopathologyAcross the Cultural Divide: Across the Cultural Divide: The case of Ethiopian JewishThe case of Ethiopian Jewish

Immigrants in Israel Immigrants in Israel (Ben-Ezer,2006)(Ben-Ezer,2006)

- Cultural competenceCultural competence

- Cultural codeCultural code

- Parallel processParallel process

- “ “Mutual Creative Space” Mutual Creative Space”

MetukuMetuku

ConclusionConclusion

The suicide issueThe suicide issue

- Acute problem- Acute problem

- Inter-disciplinary work- Inter-disciplinary work

- Prevention strategy- Prevention strategy

The therapeutic issue (I)The therapeutic issue (I)

- -What do we do in front of concepts that belong to What do we do in front of concepts that belong to another cultural systemanother cultural system??

- -How do we create dialogue with systems of How do we create dialogue with systems of reference that are not oursreference that are not ours ? ?

- -The capacity to work with cultural concepts The capacity to work with cultural concepts unfamiliar to all the team is a crucial further unfamiliar to all the team is a crucial further development in the field of trans-cultural development in the field of trans-cultural psychiatrypsychiatry

The therapeutic issue (iI)The therapeutic issue (iI)

By trying to conceptualize otherwise we discredit a By trying to conceptualize otherwise we discredit a system on the basis of cultural difference system on the basis of cultural difference

(Edelstein 2002)(Edelstein 2002)..

A patient without any code of reference can’t A patient without any code of reference can’t express his psychopathologic suffering. It is express his psychopathologic suffering. It is

why the process of cultural referent why the process of cultural referent identification is fundamentalidentification is fundamental

))Tobie Nathan 1996Tobie Nathan 1996((