Struggles with mental illness amid the aliyah dream
Mental illness intervened and turned their dream into a nightmare. These are their stories of trial and tragedy and their dealings with the Israeli healthcare system.
Meshulam and Lisa Gotlieb, and Allen and Judy Krasna are typical English-speaking immigrants. They came from prosperous Jewish communities in the United States, Canada and Australia, and moved to Jerusalem and Beit Shemesh, cities with sizable Anglo populations. They are settled and successful and have been living the “aliyah dream.” Yet along the way, mental illness intervened and turned their dream into a nightmare. These are their stories of trial and tragedy and their dealings with the Israeli healthcare system.
Meshulam Gotlieb, 51, moved to Israel from Toronto in 1988 after completing high school. He met his wife – Lisa, a native of Melbourne – in Israel, and they married in 1992. The Gotliebs have four children, and their second child was diagnosed with borderline personality disorder (BPD) in her teens.
BPD is a mental illness marked by unstable moods, behaviors and relationships. People who suffer from BPD can struggle with feelings of emptiness and abandonment, and BPD has the highest suicide rate of any mental illness. The Gotliebs’ daughter underwent private therapy for several years before she was hospitalized at a local psychiatric hospital for almost 10 months.
During her hospitalization, says Gotlieb, the staff “at best, used protocols contraindicated by our current understanding of borderline personality disorder, and without a doubt left her traumatized and more suicidal than she had been previously.” Gotlieb declined to provide the name of the hospital.
“We realized that she needed residential care with the best possible therapy available for BPD,” says Gotlieb. “At the time, Israel did not offer any residential care that was BPD-adherent, as far as we knew. We took her abroad for the care that she needed.” In January 2015, Meshulam, Lisa and their daughter traveled to McLean Hospital near Boston. McLean is the largest psychiatric teaching hospital of Harvard Medical School and is acknowledged as one of the world’s top psychiatric hospitals. The Gotliebs had to depend on financial assistance from family to afford the steep cost of care.
“They saved her life,” says Meshulam. “They took a suicidal, self-harming, completely dysregulated person and gave her the tools and support she needed to be able to function again.”
The staff at McLean utilized dialectical behavior therapy, of DBT, to treat her. DBT is today considered the gold-standard treatment for borderline personality disorder, Gotlieb explains. Developed by Dr. Marsha Linehan in the late 1970s and early 1980s, DBT combines problem-solving with validation and acceptance of the patient by the therapist, and provides therapeutic skills in four areas.
Mindfulness improves the ability to remain present, nonjudgmental and accepting in the current moment; distress tolerance increases a person’s ability to experience conflict and difficult emotions; emotional regulation helps manage behaviors by learning how to respond rather than react to intense emotions; and interpersonal effectiveness provides techniques to allow a person to communicate with others in a direct and assertive way, thereby strengthening relationships.
After returning to Israel, the Gotliebs located a therapist who is an expert in DBT therapy, and their daughter continued her treatment here.
“The work that she did at McLean got her to a certain level, and the work that she has done over the last five years with two different Anglo therapists who made aliyah has moved her along the path,” says Meshulam.
Their daughter, who is now 21, is currently completing her bagruyot (matriculation exams), working part-time, and planning to begin her studies at Ben-Gurion University next year.
“When we got on the plane to Boston just under six years ago, we could not have dreamt of this,” says Gotlieb. “The fact that she would be alive in six years would have been a stretch. The fact that she is completing high school and starting university is little less than a miracle.” Meshulam Gotlieb is grateful that his daughter has recovered but says treatment options in Israel for BPD are still lacking.
“There aren’t enough programs here, and there are waiting lists for these programs.” In North America, he says, there is a great deal of awareness of borderline personality disorder, and serious inroads have been made in setting up appropriate treatment. In Israel, by contrast, there are far fewer trained clinicians and far fewer programs. Sadly, says Gotlieb, there are not enough psychiatrists practicing in Israel.MESHULAM GOTLIEB: ‘The fact that our daughter is completing high school and starting university is little less than a miracle.’ (Meshulam Gotlieb)
IN AN effort to spare parents and families the difficulties they went through, Meshulam and Lisa Gotlieb founded NEABPD Israel, the National Educational Alliance for Borderline Personality Disorder, with the support of several senior Anglo clinicians. The organization provides information about treatment options available in Israel and throughout the world, offers support and training to family members – through its flagship Family Connections course and peer-to-peer counseling – and advocates in the public sphere, educating both clinicians and the general public.
“We founded the organization so that no one else would go through the suffering that we went through,” says Gotlieb.
Gotlieb says that he and his family didn’t give much thought to the stigmas surrounding mental health.
“We didn’t talk about it with anyone, but we didn’t hide it. I didn’t really think twice about it. Having met a lot of families since then, I understand why people hide it, and I certainly believe that they have the right to do so. Whether they are concerned about their family member’s privacy or about how this might affect the other children if the community knew, they have the right to make this decision.
“Unfortunately, I also know that both the families and their mentally ill relatives pay a steep price for this. It’s never easy or particularly healthy to hide what’s really going on in your life from your friends, neighbors and even family. A lot of relationships that could have been supportive are lost. And unfortunately, the implicit message given to the sick person and their siblings is that having this disease is shameful and embarrassing. It’s not a message that helps anyone heal.” Gotlieb feels it is imperative to try to improve the state of mental healthcare in Israel.
“It’s all well and nice to say that there is nothing here that can be done,” he adds, “but I am working with people trying to help them get the best care they can for their relatives within the situation that they live. There is room to criticize the system here, but we have to recognize and applaud the positives while intelligently criticizing and working to change those things that need to change.” He advises parents to keep their eyes open and look for the best possible treatment options.
“Don’t just settle for whatever is being done, even though that is the easy path and is the path of least resistance. I have the greatest empathy for parents who are shocked out of their minds, bowled over, and just want to hospitalize their children or hand them over to the professionals and have them ‘fixed.’ However, once they catch their breath, they should look around and advocate for their children to the best of their abilities. If they don’t know how to do that, they should give us a call.” JUDY AND Allen Krasna (full disclosure: I have been friends with the Krasnas for more than 20 years) immigrated to Israel from the New York area in 1996 with their three-year-old triplet daughters: Gavriella, Netanya and Talia. Gavriella was diagnosed with anorexia nervosa when she was 14. Anorexia is an eating disorder characterized by low weight,self-imposed food restrictions, fear of gaining weight and a strong desire to be thin.
Judy took Gavriella to their family doctor, who at first was unsure if her weight loss indicated an eating disorder. Judy continued to bring Gavriella to the doctor to have her weight checked. After a month, she finally received a referral for treatment of eating her disorder. Over the years, Gavriella was treated through their kupat holim (health fund) as well and through private treatment. Judy, wanting to learn more about her daughter’s disease, became a member of the Academy for Eating Disorders and F.E.A.S.T. (Families Empowered And Supporting Treatment for Eating Disorders), a global support and education community for parents of those with eating disorders, and became an eating disorders parent advocate in Israel and around the world.
“When Gavriella was diagnosed,” she says, “I was a research fiend. I learned everything that I could about eating-disorder treatment.”
Judy and Allen told very few people of Gavriella’s illness when she was first diagnosed, in order to respect her privacy. Ultimately, when they needed practical help, they reached out to a group of friends and informed them. At a certain point, Judy recalls, Gavriella told her mother that most people were aware she was anorexic and that she could share that information with others.
“I never felt it was a stigma,” Judy says, “and I never treated it like a stigma. I didn’t want it to be shameful. It was an illness. I wanted it to be thought of as an illness as much as any physical illness.”
Throughout the years of Gavriella’s treatment, the Krasnas encountered most of the different frameworks of treatment that are available in Israel, ranging from health funds to hospitalization, to private eating-disorder treatment.
Gavriella began treatment through a kupat holim eating disorders clinic in late 2007. She was hospitalized in early June of 2008 and was suddenly discharged from the hospital in January 2009 – without having any alternative treatment option in place – after refusing to maintain a higher weight.
She remained in private therapy from 2009-2011. The treatment was effective, her weight stabilized and Gavriella completed her bagruyot, received her driver’s license, and began sherut leumi (national service) at the Shalva special-needs organization in Jerusalem. While in sherut leumi, Gavriella was treated by a private dietitian and a psychologist through the Meuhedet health fund, and remained stable. She spent a second year of sherut leumi at Jerusalem’s Amit Beit Hayeled, a residential facility for children from troubled homes, and worked there for an additional two years.
In August 2015, Gavriella decided to have herself hospitalized.
“She told us that she wanted to learn to control the eating disorder, and for it not to take up space in her head anymore,” says Judy.
Gavriella was hospitalized at Sheba Medical Center in Tel Hashomer for three months and then went to Bayit Shikumi in Ramat Yishai in northern Israel, undergoing treatment at Rambam Medical Center while living in the area. Over the next several years, Gavriella spent time in various hospitals and rehabilitation centers. In the summer of 2019, she moved into an apartment in Jerusalem and she was treated by a private therapist.
Tragically, Gavriella was unable to overcome her illness, and on June 29, she died by suicide.ALLEN AND JUDY KRASNA made aliyah from the New York area in 1996. (Photogeny Photography)
WHILE JUDY speaks critically about deficiencies in treatment for eating disorders in Israel, she hastens to add that many of the same treatment issues exist in other countries. She focuses her comments on three main issues.
“The number-one ‘fail,’” she says, “is that depression and suicidality are present in a huge percentage of eating-disorder patients as a side effect. The problem in this country is that you can either be treated for an eating disorder or suicidality, but not both. As soon as a patient says, ‘I am having suicidal thoughts,’ they are automatically pushed off to psychiatric care, even though the two are intertwined.” Judy recalls when Gavriella was being treated in a psychiatric unit and asked for a dietitian. The hospital refused. When she told them she had an eating disorder, they said if she had an eating disorder, she couldn’t be treated for suicidal thoughts, and if she was in the psychiatric unit, she couldn’t be treated for an eating disorder.
Second, Krasna says that treatment for anorexia in Israel does not, for the most part, include evidence-based treatment, such as cognitive behavioral therapy (CBT), which has been proven to be effective. CBT is a problem-focused type of therapy in which the therapist assists the client to find and practice effective strategies to decrease symptoms of the disorder. It also does not generally include dialectical behavior therapy (DBT, described above) or family-based treatment (FBT), which treats the family as a whole unit, and provides parents with the tools to get their children to eat, and handle the stress that accumulates as a result. In FBT, the role of parents is to provide nutrition by actively feeding their child.
“When I went to her treatment team, and I asked them why they weren’t using DBT, CBT or FBT – treatments that are considered to be the gold standard and that have evidence to prove that they work – they said, ‘We don’t do that here.’” The third deficiency in treatment, says Krasna, is that most clinics do not track outcomes. Judy recalls attending a committee discussion in the Knesset, in which a member asked a representative from the Health Ministry about the number of people in Israel with eating disorders, and of those, the number who were in hospitals or treatment centers. The representative replied that they simply did not have that information.
“When Gavriella left every single treatment center, there was never a follow-up phone call or questionnaire to evaluate how she was doing. The bottom line is that they are doing all of this treatment, and they don’t know if it works.”
Allen Krasna suggests that doctors’ attitudes can be problematic.
“In Israel, the whole medical system is patronizing. It is very much that the doctor knows, and you are supposed to be the patient and shut your mouth.”
He recalls that early on, Judy had mentioned the importance of family and parents in treatment.
“Not only were they not taking advantage of the family, but the family – especially parents – were considered to be a part of the cause and the problem, and they tried to push us off as much as possible.”
Judy says that not including families in the treatment of eating disorders is a significant drawback.
“This is a really big problem because you are usually talking about adolescents who live at home. They are not living in a vacuum and [they] are going back into the family.”
Judy feels that therapists need to work with parents and bring them onto the team so the patient knows there is one united front.
“I tell parents that they need to educate themselves and need to become empowered. The only way is to learn about eating disorders and do the research.”
Parents also need support, she notes, and recommends www.feast-ed.org as an excellent resource for information and support.
On an individual level, the Krasnas had some excellent experiences with some of Gavriella’s therapists.
“There is good treatment in this country,” says Judy. “At Gavriella’s funeral and throughout the shiva [mourning period], the professionals who treated her over the years came. They were devastated and took it as a personal loss, not in a guilt sense, but in a caring sense. We had some damaging, awful treatment, but we also had some exceptional treatment. On paper, we have a good system, better than many other countries, but ‘on paper’ is sadly not reality.” The frustration in her voice is evident when Judy says, “We have cutting-edge treatment in so many different specialties. Why is mental health not an equal priority, and why is nothing being done to change the status quo? If Gavriella were diagnosed today instead of 13 years ago, the treatment would be exactly the same. That, to me, is what is most unacceptable.”This is the second in a series of articles on mental health treatment in Israel.
