Guidance and Training Center for the Child and Family

Bethlehem - Palestine

CBT In Palestine

Samah Jabr MD, Guidance and Training Center for the Child and Family, Bethlehem, Palestine; Birzeit University, Palestine; George Washington University School of Medicine and Health Sciences, Washington, D.C. Wasseem El Sarraj, Manchester Mental Health and Social Care Trust, NHS, Manchester, UK Alan Kessedjian PhD, University of Birmingham, UK Michael Morse MD, MPA, George Washington University School of Medicine and Health Sciences, Washington, D.C. ABSTRACT
Background:
Cognitive Behavioral Therapy is an effective and efficient treatment for a wide variety of disorders across diverse populations. Prior to 2009, CBT had limited reach within Palestine; however in 2009, one of us, (S.J.) led a Palestinian steering group to make localized cost effective CBT training available to Palestinian providers.

Demographic Information
• In the West Bank and Gaza, total population of approximately 4.4 million (2013). • 40% of the population are under 15 years of age (2011). • Literacy rate age 15 and above: 96% (2011). • Poverty rate: 25% (2011). • Unemployment rate: 23% (2012)3

Intervention:
Our first initiative was led by one of us (A.K.) an experienced UK Clinical psychologist and CBT trainer who developed a ten day Introductory Practitioner Course taught in three blocks over a twelve month period from the fall of 2009 to the fall of 2010. This course was jointly led by S.J. to ensure maximum utility and cultural appropriateness as well as allowing the training to be delivered in Arabic. The Introductory Practitioner Course was inclusive of basic CBT theory for Axis I disorders, skills development, and monthly group supervision; it also increased familiarity and confidence utilizing the revised Cognitive Therapy Scale (CTS-R, James Blackburn & Reichelt, 2001).1 The training program was informed by the UK CBT Competency Framework (Roth and Pilling, 2007),2 and it included lectures, role plays, interactive group work, and self directed learning. Further training included trauma-focused CBT, cognitive profile of personality disorders, CBT for psychosis, CBT for child group psychotherapy, and DBT. The initial CBT training targeted 33 mental health professionals, dozens more mental health professionals have been trained in subsequent trainings, and CBT informed training has reached hundreds of health providers working in the West Bank.

Mental Health Training and Service Provision
• Restrictions on freedom of movement that are imposed by Israel makes it difficult for Palestinians to train abroad. Thus international cooperation is important for capacity building of Palestinian mental health human resources. • Our clinical impression: Rate of mental disorders is roughly the same as in Europe. • There are roughly 20 psychiatrists and fewer PhD-level psychologists in Palestine; and it is estimated that 2% (roughly 2.5 million dollars) of the Palestinian Authority’s annual health budget is allocated for mental health.  

Breadth of CBT-informed Training
CBT-informed training has been provided to numerous institutions and practitioners through: • World Health Organization-sponsored courses on mental health in primary care which was provided for 750 physicians and nurses in 2011 • A practice parameter, Behavioural Health Aspects of Diabetes Management, published by the United Nations Relief and Works Agency for Palestinian endocrinologists and primary care doctors • Courses for Palestinian correctional facility physicians, nurses, and other health workers • Two intensive courses, one that was an introduction to CBT and the other which was trauma focused CBT for counselors at the YMCA • Courses for counsellors and primary care clinicians in the Ministry of Health • Courses on group CBT for children, provided to counselors working at governmental schools and private schools • The introduction of CBT training as part of the curriculum for Bethlehem University’s Diploma for Rehabilitation of Drug Addiction • Distribution of CBT self-help materials translated by Bethlehem’s Guidance and Training Center • Training workshops—provided by staff from the Guidance and Training Center, S.J and A.K—at the Cairo-based International Congress on Psychiatry in 2013  

Results:
At the Bethlehem-based Guidance and Training Center, where CBT training has been the single most important innovation over the past four years, annual records show: an increase in number of patients, a decrease in the total number of sessions, improved patient satisfaction, and improved clinical results. A survey completed by the Guidance and Training Center demonstrated that clinicians throughout the West Bank find CBT applicable and clinically effective and that they favor the modality of CBT over other psychotherapeutic modalities.

Key Points
• Certain features of CBT—including the clarity and face-validity of core CBT concepts, the modularity of CBT training, and the cost-effectiveness of CBT—make it useful with Palestinian patients with psychiatric, substance abuse, and chronic medical illnesses. • The introduction of CBT into non-psychiatric medical care can both improve somatic medical care and serve to de-stigmatize psychiatric care. For example, a CBT conceptualization of the cognitions, behaviors, emotions, and physiology associated with diabetes medication non-adherence can elucidate a path to medication adherence and simultaneously demonstrate similar barriers to care faced by patients with somatic and psychiatric problems. • CBT can serve as a common language that unifies the efforts of mental health and medical providers in Palestine, allowing Palestinian clinicians—often in partnership with international partners—to advance healthcare quality in Palestine.

Conclusion:
Given that Palestine faces limited financial and mental health human resources, given the face validity of CBT to patients, and given the usefulness of CBT to clinicians, it is an efficient and culturally appropriate means of advancing healthcare quality in Palestine.

References:
1. Blackburn, I. M., James, I. A., Milne, D. L., Baker, C., Standart, S., Garland, A., & Reichelt, F. K. (2001). The revised cognitive therapy scale (CTS-R): psychometric properties. Behavioural and Cognitive psychotherapy, 29(04), 431-446. 2. Roth, A. D., & Pilling, S. (2007). The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders. London: Department of Health. 3. Palestinian Central Bureau of Statistics. Indicators. Accessed September 15, 2013. http://www. pcbs.gov.ps/site/881/default.aspx#Population