درمان سیستماتیک فرهنگی در کیبوتس: ارتباطات و درمان بی اشتهایی عصبی مبتنی بر خانواده

A cultural approach to therapy assumes that community organization and social ideology can contribute to the genesis and maintenance of mental health problems, and also to their resolution. Cultural systemic therapy applies this insight to all relevant levels of the family-community ecosystem. This is demonstrated by focusing on the treatment of anorexia nervosa in the Israeli kibbutz. We analyze the confluence of cultural characteristics with the anorectic syndrome and then illustrate in a case study of how these characteristics can be employed in therapy. Two particular interventions are delineated to document the powerful impact that can be achieved when this approach is applied to severe and long-term disorders: the establishment and ongoing collaboration with an expanded community/family team and a home confinement program.

weltanschauung, apparently cutting across different schools of psychotherapy, is an improved understanding and consideration of culture. Looking at published books, training programs, or actual field work, it seems that more clinicians than ever before are applying cultural concepts to the assessment of pathology and resources within context, and to the planning and implementation of treatment programs (Sue & Sue, 1990). Moreover, there is an increased awareness that employing a culturally sensitive approach is essential for making mental health care more accessible and effective among underserved populations (Rogler & Cortes, 1993). Family systems theory is readily amenable to such a development because it is fundamentally concerned with a contextualized wide-angle view of human action. Initially, it focused therapists' attention on the way that family processes shape behavior. Subsequently, the concept of the problem-defined system created a broader perspective that includes the myriad of social contexts playing a part in maintaining the problems (Anderson, Goolishian, & Winderman, 1986). This expansion has been supported by theory and research that demonstrated the effects of multilevel social processes on human development (Bronfenbrenner, 1986), and the influence of human-service-provider institutions on therapy (Elizur & Minuchin, 1989). At the same time, systems therapies have been developing ways of working with larger social organizations, thereby creating multileveled solution-defined systems Carpenter & Treacher 1993, Elizur 1996b and Henggeler, Melton, & Smith 1992. The publication of Ethnicity and Family Therapy (McGoldrick, Pearce, & Giordano, 1982) was an important milestone in the development of a more integrated ecological framework that is cognizant of the role of culture in family structural patterns and belief systems. Since then, family therapists have learned to think of families as meaning-producing systems that are also parts of the wider society and involved in intersubjective meaning-shaping dialogs with their environment. But because people belong simultaneously to multiple contexts, and their world views are shaped accordingly, simple descriptions of families according to their ethnic backgrounds are insufficient to encompass the complexity of social and psychological interactions (DiNicola, 1997). Moreover, the very heterogeneity of ethnicity, especially the ethnic group as defined by Western culture, makes it difficult to attribute cultural stereotypes to specific families. This point was made following an extensive review of research on psychotherapy with culturally diverse populations (Sue, Zane, & Young, 1994). Homogeneous ethnic groups were more the exception than the rule and within-group differences were found to defy generalizations, all the more so within societies composed primarily of immigrants. Hispanics, for example, immigrate to the United States from as far away as the southern parts of Chile, yet together with those who are born in Texas, Mexico, and Brazil, are considered Latin Americans. Moreover, within-group cultural diversity has also been increasing as a result of worldwide migration. Thus, acculturated Asian Americans will describe their problems as emotional, whereas more traditional Asian Americans see them as either physical or work-related (Tracy, Leong, & Glidden, 1986). Consequently, despite the increasing interest in psychotherapy with different ethnic groups, studies with solid research outcomes are few and far between. In this article, we take the view that when a social system has a highly cohesive cultural world view, the understanding of custom, language, community organization, and ethnic beliefs will be especially crucial for designing effective engagement and intervention practices. For example, in traditional Arab communities that have a negative attitude toward concern for self, Western psychotherapy, which has an emphasis upon self and individualism, can be counterproductive. With these clients, a form of intuitive metaphor therapy has been found to be more congruous Dwairy 1998 and Dwairy & Sickle 1996. It is for this reason that clinical work in Israeli kibbutzim (plural for kibbutz), which usually takes place in a specialized network of kibbutz clinics, has subsumed current notions of culturally sensitive family therapy (Kaffman, 1984). This integrated approach will be presented via a case study that demonstrates how culturally sensitive therapy can take into account the local context in order to change the family and community's narrative of pathology and the interactional patterns that contribute to problem maintenance. Before describing the case, it might be helpful to review the unique characteristics and aspects of community organization in the kibbutz. The word kibbutz means group, but it has come to mean a self-administered collective community, usually consisting of 200 to 700 members committed to ideals of social equality and justice. This highly cohesive social group is governed democratically, and holds weekly meetings for all members. All contribute their earnings to the kibbutz, and cooperate through committee membership to attend to economic, health, housing, and vocational needs. Though the trend is toward greater privatization, most property in the kibbutz is communally owned, members receive similar budgets and the community assumes responsibility for their differential needs, such as medical care and education. The kibbutzim, which began as small one-generation communities at the beginning of the century, are at this point in Israeli history a multigenerational network of more than 100,000 people. Obviously, the kibbutz can be defined as a culture in the sense of a shared world view, anchored in ideology, structural organization, attitudes toward religion, and strong commitment to reproducing this world view in subsequent generations ( Pare, 1996, p. 25). We can also say that kibbutz members share a common culture that is most generally defined as a set of collective guidelines (both explicit and implicit) shaping individuals' world view, emotional experience, and patterns of behavior ( Helman, 1994, p. 2). Appraising the problem-defined ecosystem The high degree of structure, communication, and attention to detail for the benefit of each and every member is a source of communal strength, yet at the same time, these same characteristics may become associated with family problems. Cohesiveness, which creates mutual support and collaboration, may turn into enmeshment, characterized by diffuse boundaries. The burdens of such enmeshment can become overbearing, depleting the resources necessary for adjustment to change under pressure and for the demarcation of interpersonal boundaries (Minuchin, 1974). This communal enmeshment can, at times, become part of a monothematic fixation on illness and disability, thereby contributing to the creation and maintenance of monoideistic disorders (Kaffman, 1991). Monoideism is a term that was introduced by Braid more than 150 years ago to describe the state/process of intense mental concentration on one dominant theme, which is characteristic of hypnosis. A century later, modern psychological research into human suggestibility, together with studies of information processing and psychopathology, have shown that increased self-focused attention occurs in various clinical disorders (Ingram, 1990). The excessive, sustained, and rigid attention is conceptualized to be a nonspecific psychopathological process, while the content variables are syndrome-specific. The clinical importance of this process was realized by Mordecai Kaffman, the founder and first medical director of the Kibbutz Family Clinics, who reintroduced Braid's concept with the addition of a transactional component that makes it consonant with the systems approach. The central element of the monoideistic pattern is an absorbing preoccupation with one set of persistent thoughts. This preoccupation has a powerful suggestive effect on the person and/or family's cognition, affect, behavior, and interpersonal transactions. Consequently, a self-contained feedback pattern is established that maintains and reinforces the monoideistic process. Over time, this pattern leads to an increased behavioral rigidity and stereotypical roles for others in relation to the patient, and a constriction of opportunities for self-expression and differentiation. Conflict and problem resolution are avoided by the preoccupation with an illness narrative, while the rigid illness-centered transactions ultimately reduce activities that bring satisfaction and fun. As monoideistic disorders become a chronic life pattern, depressive affect and feelings of helplessness are likely to prevail. In his kibbutz-based work Kaffman analyzed this commingling of internal and interpersonal processes in a variety of clinical conditions, including anorexia nervosa, paranoid disorder, obsessions, and depressive states, all of which are characterized by the predominance of compelling beliefs Kaffman 1984, Kaffman 1991 and Kaffman & Sadeh 1989. Let us observe, at this point, how these processes were manifested in the case of 13-year-old Rachel.

It has been established that different cultures have different attitudes toward illness and its psychological effects on the patient and the family DiNicola 1997 and Sue & Sue 1990. As culturally sensitive therapeutic programs continue to be developed, we expect that therapists will learn to individuate treatment by accommodating a plethora of nuances due to the inherent heterogeneity of culture. Moving beyond simple ethnic descriptions of families, we will learn how to work with cultural diversity. In this process, there is much to be gained from the observation of sameness and differences in the application of therapy within different cultural contexts. Because the kibbutz is a highly organized community with high level of cohesiveness and an ideology of mutual help, it can work in close collaboration with a culturally informed systems therapist. This makes the kibbutz a unique laboratory for the development and evaluation of cultural systems therapy. Indeed, such intervention programs have been successfully established with a variety of clinical issues besides anorexia nervosa, including somatoform disorders Elizur 1992 and Elizur 1994b, and severe and chronic psychiatric syndromes Elizur & Minuchin 1989 and Kaffman et al. 1996. The cultural systems framework was also applied to community crisis situations in which the kibbutz clinic was called for help with epidemic-like outbreaks of psychological distress, usually characterized by contagious anxiety and somatization (see Elizur, 1995). These experiences support the efficiency of ecological interventions as vital components that can increase the impact of therapy. To what an extent can the comprehensive intervention programs that were developed within the kibbutz culture be transferred to different contexts? This is not a simple issue, and though a full discussion is beyond the scope of this article, two comments that are based on the extended work experience of Mordecai Kaffman and the first author are submitted. The first relates to the clinical possibilities of applying this approach with individual cases in different contexts, while the second is concerned with the constraining effects of social policy. We have found it possible to apply a modified version of the aforementioned therapeutic program in a variety of situations outside the kibbutz, ranging from crisis intervention to the rehabilitation of chronic psychiatric patients, provided that a stable support group with sufficient resources can be mobilized. For example, extended family and friend networks have been organized by the first author in his work with committed middle-class families and the ultra-religious Jewish community in Jerusalem. Whenever necessary, home confinement was used, either at the house of friends or the family itself. However, looking at the wider social situation in Israel, we were repeatedly dismayed to note the disappointing implementation of a policy of community mental health that had been declared by the Israeli Health Ministry more than a quarter of a century ago (Elizur, 1994a). In our work with individuals who suffer from severe and persistent mental disorders, we found a close relationship between the ineffectual therapy that the patients had prior to their acceptance into our community rehabilitation program and the political, social, and economic context that determines mental health policy and practice in Israel (Kaffman et al., 1996). For example, most public funds are allocated to mental hospitals, most of which continue to adhere to conservative methods of psychiatric care. As a result of this policy, the development of community mental health programs has been sluggish, and many of the iatrogenic factors, which play a central role in the establishment and perpetuation of the mental patient career, continue to operate (Elizur & Minuchin, 1989). The point is that even though a therapeutic program is recognized to be both feasible and efficient in one culture, its implementation in a different setting is not an easy feat. Even in situations when a trainer or a consultant is asked to work in a new location, it should be assumed that training is more than imparting knowledge and expertise. The successful integration of a new approach depends on culture-sensitive work with the larger organizational context in order to bridge the gap between training on the one hand and the prevalent institutional belief system and structural organization on the other Elizur 1993 and Elizur 1996b.