Facilitators and barriers in the implementation of a culturally adapted Arabic version of Illness Management and Recovery (IMR) among Palestinian Arabs in Israel

Abstract

The Illness Management and Recovery (IMR) program has been implemented in several countries including Israel. This study examines, from the perspective of Arab practitioners, facilitators and barriers in the implementation of a culturally-adapted version of the IMR intervention among Arabs with serious mental illness in Israel. Fourteen Arab practitioners who had delivered the culturally adapted IMR were interviewed. The analysis of the interviews identiﬁed facilitators and barriers, divided into universal factors found when implementing the intervention elsewhere in the world, and culture-specific ones. Facilitators included the manual on which the intervention was based, bypassing verbal communication, ongoing supervision during implementation, the group process, co-facilitation and the cultural adaptations. The barriers included three universal ones: Meeting needs beyond IMR due to service shortage, Reputation is everything: Self- and social stigma and Pulling the others back: Difficulties in reading and writing—and one that was culture-specific: family over-involvement. Identifying facilitators and barriers in the implementation of the adapted IMR can contribute to the implementation of evidence-based practices (EBPs) in the mental health area. Notably, multiple culture-specific facilitators have been identified, as opposed to only one culture-specific barrier, suggesting that cultural differences may be overcome in implementing EBPs developed in the West.

Keywords

culture adaptations evidence-based practice (EBP)Illness Management and Recovery (IMR)mental health Palestinian-Arabs in Israel

Introduction

The growing availability of evidence-based practices (EBPs) has made it more likely for people with serious mental illness (SMI) to receive effective services delivered with high fidelity (Bond & Drake, 2019). Questions about their cultural relevance have been raised because EBPs are typically based on Western research and may therefore lack in cultural sensitivity because they are not adapted to specific cultural characteristics of both service providers and users, as well as to the local social contexts (Cabassa & Baumann, 2013; Kirmayer, 2012). Thus, cultural adaptations may be needed to implement EBPs in non-Western contexts successfully (Hasnain et al., 2011).

Several recommendations have been made to facilitate cultural adaptation of EBPs, including incorporating cultural beliefs and values (Heim & Knaevelsrud, 2021; Heim & Kohrt, 2019). In Arab societies, successful implementation must consider the values of family members, the stigma associated with mental illness (Abdullah & Brown, 2011), as well as religious and spiritual beliefs (Al-Makhamreh & Libal, 2011; Gearing et al., 2013). Gearing et al. (2013) identified 78 barriers to the implementation of mental health services in Arab countries. These include culture-specific factors such as beliefs and values, as well as the expectation for immediate instrumental or concrete support (Al-Krenawi & Graham, 2001). They also include universal factors such as access to and availability of services and client long-term engagement and persistence. Finally, Gearing et al. (2013) identified 37 facilitators, including consideration of the community's culture and integration of traditional interventions, as well as the development of culturally adapted strategies. An example of new programs in this area of transcultural psychiatry includes the Multicultural Paramedical Center at Achva College in Israel (https://english.achva.ac.il).

To support the engagement of Arab clients in mental health services, Gearing et al. (2013) proposed three modifications: (1) working with the local cultural environment to increase the cultural relevance of treatment and reduce stigma; (2) facilitating financial and physical access to treatment; and (3) adopting a more authoritative medical approach to treatment interventions, rather than individual psychotherapy, which may be challenging in Arab culture because it involves confiding in strangers.

Illness management and recovery

Despite the consensus regarding the need for cultural adaptation of EBPs for Arab clients, barriers and facilitators to their cultural adaptation have not yet been examined in the specific context of the Arab society in Israel. Illness Management and Recovery (IMR; Mueser et al., 2002, 2006) is a leading intervention designed to help people with SMI progress towards recovery goals, and acquire knowledge and practice skills to manage their symptoms. It is based on two manuals: one for the client and the other for the facilitator. During the IMR sessions, the facilitator and client collaborate in studying the various topics, practice skills, and plan homework assignments together. In some sessions, a client's significant other may be included (Mueser et al., 2002).

IMR has recently been at the focus of attention in the field of mental health, including in Israel. However, Arab facilitators have reported that although the IMR is relevant to their society, it requires cultural adaptation (Daass-Iraqi et al., 2019). Indeed, while being extensively implemented in Western societies (McGuire et al., 2017), the IMR has hardly been implemented in traditional societies apart from Japan, where it was proven effective (Fujita et al., 2010). The purpose of this study is to examine barriers and facilitators to the implementation of the client manual of the IMR's culturally adapted version in Arab society.

Arab society in Israel

Arabs constitute 21% of Israel's population. Their culture differs from the largely modernist, individualist Jewish majority culture in that it is collectivist and traditionalist, with strong conservative and patriarchal values. In particular, it is characterized by a stronger tendency to attribute mental illness to external or supernatural causes and by close involvement of the family in decision-making in the various stages of the treatment and recovery process (Daass-Iraqi et al., 2019; Khatib & Abo-Rass, 2022). Although more religious than Jewish society, Arab society in Israel is heterogeneous in terms of both religiosity and religious affiliation, with 85% being Muslim, 7.3% Christian and 7.7% Druze (Central Bureau of Statistics, 2019). Notably, it is undergoing modernization, as evidenced by a sharp increase in higher education enrollment, improvements in the status of women, urbanization, and higher standards of living. However, traditional norms and values endure (Azaiza, 2013), including the reliance on the extended family for support, as opposed to turning to outsiders for support, or the tendency to view severe illness as divine punishment. This is especially true when dealing with sensitive subjects, such as medical practices. Many Arabs in Israel, of all religions, seek both traditional and modern therapy. Christian Arabs are more open to modern therapy and less reliant on traditional therapy than are Muslims and Druze (Al-Krenawi & Graham, 2011). Overall, the Arab minority is markedly different from the Jewish majority regarding mental illness and recovery, as well as to the provision and consumption of social services, including mental rehabilitation (Roe et al., 2019).

The current study

Our study was conducted in central and northern Israel, examining both the process of implementing the culturally adapted version of the IMR and its effects on recovery from mental illness. Most participants in the IMR intervention groups who cope with SMI (90%) were Muslim and the rest Christian (6.7%) or Druze (3.3%). About 80% of the treatment group members defined themselves as “religious” or “traditional” (i.e., moderately religious). Most lived with their families (80.7%) and some lived alone (9.3%) or in supported housing (10%).

Prior to examining its implementation, IMR was culturally adapted to our target population. The adaptation process (2016–17) included reviewing the literature on Arab society in Israel in general, on Arabs’ utilization of mental health services, and on models for cultural adaptation of EBPs in the mental health area. It also included interviewing local professionals to elicit recommended adaptations. These were subsequently integrated into the IMR manual, translated into Arabic, and used to train Arab practitioners. The culturally adapted Arabic version of IMR was found to generate significant clinical improvement in recovery, illness management, hope, and quality of life, with more than half the clinical groups showing improvement (Daass-Iraqi et al., 2020). Given that improvement and in order to promote further improvements in this and other interventions, our research questions were:

What factors facilitated the implementation process?

What factors impeded the implementation process?

What cultural aspects were related to these barriers and facilitators?

Methods

Participants

Twenty-two Arab practitioners who had delivered the culturally adapted IMR were invited to participate in a 60- to 120-minute follow-up interview. Fourteen (63%) agreed. Participants were mostly female (n = 11, 78%), aged 26–46 (M = 35.42 years, SD = 5.96; see Table 1). Two were Christian and the rest Muslim. Six (43%) had a master's degree, five (36%) had a bachelor's degree, and the remaining three (21%) had high school education. Participants reported previous psychiatric rehabilitation experience ranging from two to 13 years (M = 4.73, SD = 3.00).

Table 1.

Participants’ demographic information.

	Name	Age	Education	Years in mental health system	Years outside mental health system
1	Misa	32	MA	7	2
2	Fatma	26	MA	3	0
3	Lamis	46	Highschool	6	20
4	Ahmad	37	BA	6	4
5	Ali	39	MA	5	1
6	Faras	33	MA	5	5
7	Nasreen	38	BA	2	7
8	Jasmin	40	BA	4	10
9	Salam	38	BA	13	2
10	Sabah	41	Highschool	1.5	11
11	Sahab	30	BA	4	1
12	Nur	40	Highschool	6	15
13	Safa	29	MA	2	6
14	Maram	27	MA	1.7	2

Procedure

The practitioners completed a 3-day training in the culturally adapted IMR and received fortnightly supervision throughout the 7-month implementation. Parallel to the training, 13 IMR groups started; 12 of them were co-facilitated. Initially, these groups were attended by 102 Arabs with SMI and psychiatric disability of at least 40% according to National Insurance Institute regulations (excluding people with severe cognitive impairments and acute psychotic conditions). Previous research estimated that of 86% of Israelis with psychiatric disability, at least 40% had a psychotic-related disorder (Struch et al., 2009). Therefore, most participants in our sample likely had a psychotic-related disorder.

Semi-structured interviews

Interviews of 60–120 minutes were conducted by the first author—a Palestinian-Arab Muslim woman living in the town of Tira and working as an occupational therapist in the field of community mental health. The interviews included 18 questions on implementing the culturally adapted IMR and perceived facilitators and barriers to its success. The first part of the interviews included five descriptive questions about the training in the IMR: issues discussed, strategies used, and the training process. Next, five questions were used to describe the implementation, focusing on facilitators and barriers (e.g., “What factors contributed to the implementation of the intervention?”). The next two questions evaluated the implementation (e.g., “What parts do you think were effective or received positive feedback from clients?”). Finally, four questions evaluated the adaptations (e.g., “What is your opinion about the cultural adaptations that were made?”).

Data analysis

The interviews were recorded, transcribed, and analyzed using the thematic content analysis approach (Braun & Clarke, 2006). They were conducted and analyzed in Hebrew, and selected quotes were translated into English by the authors. We deliberately searched for facilitators and barriers, and then divided them into universal and culture-specific ones. In the first stage, after reading all the interviews thoroughly, we performed open content analysis, noting all categories raised by the participants, and sorting them into facilitators or barriers, resulting in initial categories. The second stage involved further analysis by two Jewish researchers: a social worker and IMR expert, and a researcher in the mental health area (a woman and a man, respectively). To ensure reliability, all three of the authors discussed each dimension carefully and compared our conclusions with regard to the themes. In the third stage, participant quotes were selected. Finally, the categories and subcategories were reviewed several times by all three analysts, until consensus was reached. At this point, we decided to divide facilitators and barriers into universal vs. culture-specific ones. We then reviewed all categories and subcategories again, refined their titles, and selected the quotes that best represented them (Braun & Clarke, 2006).

Ethical considerations

Ethical approval was obtained from the University of Haifa. All participants received an explanation about the study and signed an informed consent form. They were informed that their privacy would be maintained, and all identified details were deleted. In reporting the findings, pseudonyms were used throughout.

Results

Our analyses addressed the two categories of facilitators and barriers: universal and culture-specific. The universal facilitators and barriers partly overlap with the existing literature on IMR facilitators and barriers and appear relevant to the implementation of any culturally adapted intervention. Our culture-specific findings appear more specific to Arab society. Of note, the distinction between universal and culture-specific factors is not clear-cut and thus we address elements of both as relevant.

Facilitators

Out of the eight facilitators identified, five were considered universal and two culture-specific (see Table 2).

Table 2.

Facilitators.

Category	Subcategory	Sample quotes
Universal categories
1. The manual	Partnership with the client	Ahmad: The manual is … respectful of the clients; it makes them feel like partners. Faras: The manual … made them feel like they have a place of their own in controlling the knowledge and communicating with Arab facilitators in Arabic.
	Promoting the intervention	Salam: Dividing the material into topics, the organization, the language, the personal story at the beginning of each session – all helped raise the clients’ motivation to share and listen. Ali: The manual enabled the clients to keep learning even after the sessions have ended, as well as share the knowledge acquired with family members and therapists.
2. Bypassing verbal Communication		Jasmin: The simulation strategy is effective, clear and simple, and the clients related to it. Nasreen: The simulations were the most effective. They gave the clients power and tools for coping, and helped them acquire communication skills. Sabah: Creative activities … stirred them up and helped them remain attentive. Ali: They found it difficult to … express emotions … a cultural thing, perhaps the result of harsh education. We used art … to help them ….
3. Ongoing supervision during implementation		Fatma: Implementing the intervention while receiving training and supervision helped us acquire knowledge and skills … [and] receive help in dilemmas and challenges we encountered [in the field].
4. The group process	Improved client interactions	Nasreen: The clients have a great need for a platform to express themselves due to the shortage in mental health services. Most of them took part in a therapy group for the first time in their life … The group was a haven in their life … They would wait for it.
	Promoting communication	Ahmad: Given the lack of other therapeutic services, the group space offered [the clients] their first opportunity to unburden and grow.
	Sense of security	Ahmad: The group was a highly respectful and secure space that contained the pain and led to growth and the realization of wishes.
	The group as family	Sahab: Many clients felt alone despite living with their families, and the group became a source of a sense of belonging to a space with similar characteristics …. Helping its members think about change and set personal targets and goals.
	Peer learning	Sahab: They benefited from peer learning … and personal relationships were formed. Some relied on each other for help even outside the group meetings. Ali: The group managed to provide solutions and we [the facilitators] were its shell. This is a special thing you do not encounter in many groups.
5. Co-facilitation		Fatma: … balancing each other and mirroring our work to one another. The combination of two professionals from different backgrounds can contribute greatly to the facilitation process. Ali: The presence of the other facilitator who had great experience contributed to effective coping with complex issues. Ahmad: Co-facilitation reduced the emotional burden ….
Culture-specific categories
1. Cultural adaptation	Shared decision-making with the family	Sahab: The family's involvement and siding with the professional and client, and its ability to counteract the barriers in the process, empowered the clients … This is my first training that refers to the family issue respectfully and profoundly.
	Culturally adapted training	Fatma: This is my first time studying exclusively with Arab professionals who understand the complexity and needs of this society and I don’t have to … explain … to others about the issues I encounter. Sabah: For me, the studies were a welcoming home and empowered me greatly. Faras: The fact that the training was in an Arab town broke down many emotional barriers. If it were mixed, we would have been preoccupied by other issues and had less energies. This way, there was less hypocrisy, we were truer and more honest.
	Adapting the manual (a): Contents added	Misa: The main strength of the manual is that it provides coping strategies that can be applied in everyday life … The quotes … are similar to the experiences of Arab clients. Safa: The fact that an issue is mentioned in the manual … has encouraged [the clients] to talk about it in the group.
	Adapting the manual (b): Contents removed	Nur: The decision to remove the section on drugs and alcohol was spot on. Most of the clients are Muslim, and Islam absolutely prohibits drug and alcohol abuse.
	Adapting the manual (c): Language	Nur: This finally enabled us to talk with the clients in their own language. Ahmad: The fact that the material was in Arabic helped the clients internalize and remember it. Nasreen: The Arabic terms helped us learn and understand the various strategies, making us better professionals.
	Integrating religious-spiritual approaches	Nur: The course provided us with answers to dilemmas … helped me understand that using religious contents is a complementary strategy to medicinal therapy.
2. Home visits for partnership with the client and family	Familiarity with the client's environment	Salam: Visiting M.'s house was important for me, to get to know his wife and daughter whom he mentioned frequently in the sessions …. He lives in the middle floor in a building he shares with his brothers and parents.
	Understanding the family system	Ali: In the home visit, we paid our respect for the male head of the household, which breaks the ice … and enables progress in the rehabilitative process.
	Establishing trust	Misa: The home visits contributed to establishing trust with the clients and families, contributing to retention …
	Empowerment and motivation	Salam: He's very happy I visited them at home. My visit empowered him and increased his motivation in the sessions held afterwards.

Universal facilitators

These included: (1) The manual; (2) Bypassing verbal communication; (3) Ongoing supervision during implementation; (4) The group process; and (5) Co-facilitation.

The manual

This was identified as a co-facilitator of the intervention, helping the participants focus and motivating the clients to share their personal experience, and as a source of partnership with the clients, promoting their sense of control and providing opportunities to acquire knowledge. Most participants described the manual as respectful of the clients, particularly because it was written in Arabic. As one of our participants, Ahmad, stated, “The manual is… respectful of the clients; it makes them feel like partners.” According to Faras, “The manual… made them feel like they have a place of their own in controlling the knowledge and communicating with Arab facilitators in Arabic.”

This aspect of using the manual not only facilitated dialogue and rapport, but also enabled “extending” the activity beyond the sessions. As Ali commented, “The manual enabled the clients to keep learning even after the sessions have ended.”

Bypassing verbal communication

This was mentioned by about half of the participants as enabled by acquiring role-play skills and using art, specifically for modeling new coping skills and practicing them with the clients. Although the use of role-play and art is universal (Meyer et al., 2010), it had a culture-specific aspect in enabling clients to overcome stigma by relating to their problems indirectly, particularly given the cultural tendency to avoid emotional self-expression (Zolezzi et al., 2018). Once the group leaders realized the effectiveness of this approach, they used it extensively. According to Nasreen: “The simulations were the most effective. They gave the clients power and tools for coping, and helped them acquire communication skills.” Ali described how art helped the clients express themselves. In the last session, they were given objects through which to describe their recovery process:

They found it difficult to… express emotions… a cultural thing,… We used art… to help them… Had I asked them to put it into words, they would probably not have been able to… They described the process they had undergone like a dove that… slowly began learning to fly. It fell occasionally on the way, but despite the falls, she mustered enough strength to reach the summit.

Sabah concluded: “Creative activities… stirred them up and helped them remain attentive.”

Ongoing supervision during implementation: Keeping it close together

More than half of the participants felt more competent in providing immediate professional response during the implementation. Fatma: “Implementing the intervention while receiving training and supervision helped us acquire knowledge and skills… [and] receive help in dilemmas and challenges we encountered [in the field].” In this positive feedback loop, the facilitators experienced growing together with the clients, and reported being better able to satisfy their cultural expectations for concrete, “authoritative” solutions (Al-Krenawi & Graham, 2001). Thus, the parallel procedure empowered both facilitators and clients. Importantly, this is a characteristic of EBPs in general, retained in the culturally adapted version. According to Safa: “The fact that the training was provided in parallel with the implementation gave us the professional confidence that what we were doing was evidence-based.”

The group process

Sharing experiential knowledge was referred to by many participants as an important source of support. The group space was similar to a family in contributing to the clients’ sense of belonging, similar coping, and mutual support. This category included five subcategories: (1) Improved client interactions that increased their motivation and commitment. Nasreen stated: “The clients have a great need for a platform to express themselves due to the shortage in mental health services. Most of them took part in a therapy group for the first time in their life… The group was a haven in their life…” (2) Promoting communication. According to Ahmad, “Given the lack of other therapeutic services, the group space offered [clients] their first opportunity to unburden and grow.” (3) Sense of security that enabled growth. Ahmad reported: “The group was a highly respectful and secure space that contained the pain and led to growth and the realization of wishes.” (4) The group as family. According to Sahab: “Many clients felt alone despite living with their families, and the group became a source of a sense of belonging.” (5) Peer learning. Ali stated: “The group managed to provide solutions and we were its shell. This is a special thing you do not encounter in many groups.” Again, although the effectiveness of group processes is a universally recognized facilitator, within the current context it also had a culture-specific aspect in that this was a unique experience for many clients due to the shortage in mental health services for Arabs.

Co-facilitation: The power of 2

Several interviewees reported that when working in tandem, they enriched and empowered each other, compensating for weaknesses and relieving each other's emotional burden. Finally, and more culture-specifically, given the expectation for an immediate and concrete solution, the additional facilitator helped identify and address clients’ needs rapidly. According to Fatma: “The combination of two professionals from different backgrounds can contribute greatly to the facilitation process.” Ali reported: “The presence of the other facilitator who had great experience contributed to effective coping with complex issues.” Lastly, Ahmad stated: “Co-facilitation reduced the emotional burden… ”

Culture-specific categories

Cultural adaptation: An empowering approach

All interviewees mentioned coping with challenges that are different from those addressed in the West due to different perceptions of illness and recovery. This category included four subcategories:

(1) Shared decision-making with the family was mentioned by all participants, whether as a facilitator or as a barrier. In Sahab's words: “The family's involvement and siding with the professional and client, and its ability to counteract the barriers in the process, empowered the clients… This is my first training that refers to the family issue respectfully and profoundly.” Three specific adaptations were made. First, and unlike the original IMR program, we developed a brief Arabic manual for the family. Second, we included family members in the final, festive meeting. Finally, we held separate individual or group meetings with family members. According to one participant, involving the family in these various ways was essential to overcoming barriers in the process, some of which were due to lack of or excessive family involvement.

Several participants referred to the rarity of this approach in their professional experience. According to Ali, it helped promote personal goals. For example, one client began working in a clothing store after spending years in a sheltered workshop due to the family's refusal to allow her to leave it. Ali attributed this achievement to the shared decision-making with her family.

(2) Culturally adapted training was mentioned by nearly all interviewees. The fact that the training took place in an Arab town was significant. Its central location made it accessible, but more importantly, it provided a familiar environment. Together with the fact that all participants were Arabic speakers, this facilitated the sharing of culturally relevant difficulties and dilemmas. Fatma reported: “This is my first time studying exclusively with Arab professionals who understand the complexity and needs of this society and I don’t have to… explain… to others about the issues I encounter.” According to Faras, participants could express themselves more openly and candidly than in their much more familiar training experience, where Arab practitioners work together with Jews in less accessible locations and use Hebrew. In Faras’ words, “If it were mixed, we would have been preoccupied by other issues and had less energies. This way, there was less hypocrisy, we were truer and more honest.”

(3) Adapting the manual to Arab clients was emphasized by most participants. They stressed the addition of culturally adapted contents, such as explanation about the religious context of mental health as well the removal of others, such as the section on alcohol and drug abuse, which is forbidden by Islam. The manual was translated into accessible, spoken Arabic, as opposed to many other interventions in Israel that use Hebrew materials, making it more accessible to both clients and facilitators and improving their self-expression. According to Misa: “The main strength of the manual is that it provides coping strategies that can be applied in everyday life… The quotes… are similar to the experiences of Arab clients.”

(4) Integrating religious–spiritual approaches was highlighted by half of the participants. The relation between religion and mental illness was frequently discussed: many clients viewed their illness as the result of distancing from religion, and turned to traditional healers for help. For some, the encounter with such healers was experienced as disturbing due to their use of exorcising techniques. The manual emphasized that there was no relation between lack of devotion and mental illness, and that religion complemented but did not replace medication. Following their training, the facilitators felt confident in discussing those issues with their clients and providing them with concrete solutions. According to Nur, “The course… helped me understand that using religious contents is a complementary strategy to medicinal therapy.”

Home visits

The second culture-specific facilitator category was mentioned by some as important for building partnership and trust with the client and family. Clearly important in any intervention, this is particularly so in Arab society, where more than 80% of the clients lived either with or very near to their original families (Fakhr El-Islam, 2008). Some facilitators made home visits that enabled them to become familiar with the clients’ environments, empowered and motivated the client (e.g., as suggested by Salam), and enabled the facilitators to identify key contacts in the family. Ali reported: “In the home visit, we paid our respect for the male head of the household, which breaks the ice… and enables progress in the rehabilitative process.” Finally, as mentioned by Misa, “the home visits contributed to the implementation by building trust in the program, resulting in greater retention.”

Note, however, that some participants objected to home visits. According to Fatma: “Most members of our group were young…. And they chose not to involve their families in the process.” This is related to family over-involvement as a barrier, discussed below.

Barriers

Out of the four barriers identified, three were universal: meeting needs beyond IMR; self- and social stigma among the group participants; and difficulties in reading and writing—and one was culture-specific: family over-involvement (see Table 3).

Table 3.

Barriers.

Category	Select quotes
Universal categories
1. Meeting needs beyond IMR due to service shortage	Jasmin: There is not a single treatment coordinator in our entire area. In addition to the shortage of mental health professionals and services, there are hardly any psychologists, and the turnover among professionals is very high…. It was hard to set a boundary [to the clients], because difficult things came up, and there was nobody else to meet their needs… the clients require ongoing support. Salam: I have accompanied her several times for meetings in the welfare services… I believe this would promote her rehabilitation and recovery process.
2. Reputation is everything: Self- and social stigma	Jasmin: People don’t know anything about their illness. They were surprised to learn that the voices they hear are a symptom of the illness, but despite their ignorance, some did not want to hear about the illnesses due to self-stigma.
3. Pulling the others back: Difficulties in reading and writing	Lamis: The functional level of the clients was low… Only one is literate. Progress was slow. Ahmad: Clients at a high functional level manage their illness more effectively… Their self-awareness is high and it is easier for them to define their recovery and set goals.
Culture-specific categories
Family over-involvement	Ahmad: We cannot talk about illness and recovery without the family being involved, we cannot set personal goals without the family being on board… if we do not work with it correctly, it might sabotage the process.

Universal barriers

Meeting needs beyond IMR: The facilitator as part-time welfare worker

This barrier was mentioned by most interviewees. Although in recent decades welfare services in all Western countries have been significantly reduced, in Israel this fact has an additional culture-specific element due to the discrimination against Arab society. Some facilitators chose to help beyond the scope of their duties in ways unrelated to the IMR intervention. For example, a mother of two had divorced her husband, and he prevented her from seeing the children. Solving this problem was her personal IMR goal, and the facilitator met her family and accompanied her to the welfare services to solve the issue. Overall, this particular personal element served as a facilitator, since without it, recovery would not have been enabled, and because it narrowed gaps between the clients. Nevertheless, it also impeded group progress towards the achievement of IMR goals and blurred boundaries between the facilitators and clients. As mentioned by Jasmin, “There is not a single treatment coordinator in our entire area.… It was hard to set a boundary [to the clients], because difficult things came up, and there was nobody else to meet their needs.”

Reputation is everything

Social and self-stigma were mentioned by some as a source of ignorance about the illness. Clients were ashamed of their condition, and this fact created a powerful motivation to avoid treatment. This also made it difficult for clients to define their goals and delayed progress by requiring group leaders to attend to their difficulty discussing practical facts about mental illness. A universal barrier, stigma is particularly significant in the Arab cultural context where a person's reputation is critical and projects on their family. According to Ahmad: “A and H are from the same village. A arrived at the first session and then decided not to continue out of fear H would leave the group and talk about it in the village… Partnering with the family, mentioned above as a facilitator, helped overcome this barrier.”

Relations within the group were affected by social stigma related to skill gaps. Although clearly a universal factor, in Arab localities in particular, “everyone knows everyone,” so meeting clients from the same community in the group made some drop out. Moreover, Sabah, for example, was told by two “high-ability” participants that being in a group with a certain less able individual would reflect on them negatively.

Pulling others back: Difficulties in reading and writing

A few interviewees referred to this as a barrier. About a quarter of participants had only elementary school education, and some were illiterate. Lamis suggested that it slowed progress in sessions, while Ahmad described how it was easier for clients at a higher functional level to set recovery goals: “Their self-awareness is high and it is easier for them to define their recovery and set goals.”

Culture-specific category: Family over-involvement

As suggested by several interviewees, family over-involvement made it difficult for the clients to set and progress towards achieving recovery goals. Some clients’ goals clashed with their families’ economic interests, such as building a home or obtaining a driving license. Typical of a family-oriented society, the entire issue involved anger at the family's lack of understanding and cooperation. Notably, some clients refused to involve their family out of fear of over-involvement, and facilitators sometimes had to deal with families that actively impeded the recovery process, as suggested by Ahmad: “We cannot talk about illness and recovery without the family being involved, we cannot set personal goals without the family being on board… if we don’t work with it correctly, it might sabotage the process.”

Discussion

The implementation of evidence-based practices (EBPs) has been extensively studied, reporting facilitators and barriers (McGuire et al., 2017; Salyers et al., 2009; Whitley et al., 2009). This study is the first to examine facilitators and barriers in implementing a culturally adapted version of the Illness Management and Recovery intervention (IMR) for Arabs with serious mental illness (SMI) in Israel. In what follows, we will briefly discuss the universal facilitators and barriers, and focus on the culture-specific ones, where the study's main contribution lies.

Universal facilitators include the manual, bypassing verbal communication, training in parallel to implementation, the group process, and co-facilitation. All are consistent with the findings of other studies on implementing the original IMR (Carlson et al., 2012; McGuire et al., 2017; Pratt et al., 2011; Roe et al., 2007; Salyers et al., 2009). Salyers et al. (2009), for example, found that the three most common facilitators reported by professionals were training (39%), the manual materials (35%), and peer or facilitator support (19%). The manual's advantage in the current study consisted of providing practical directives, and following the recommendation in the literature with regard to Arab culture (Al-Krenawi, 2019). Finally, Whitley et al. (2009) emphasized leadership and organizational culture, not found as facilitators in the current study, but also training and the facilitator team—the first highly important in the present study and the second indirectly related to it, as our findings included reference to co-facilitation.

Specifically, Gearing et al. (2013) found group processes particularly effective and acceptable in Arab culture. More generally, the use of knowledge gained by sharing lived experiences has recently become an important tool in promoting recovery—particularly in the present context due to lack of research and of practical tools to promote recovery in Arab society. In this society, psychodynamic approaches can be counterproductive, and program participants tend to respond better to immediate and concrete solutions (Dwairy, 2019; Gearing et al., 2013). Thus, programs need to enable alternative forms of expression given both the (universal) difficulty of clients expressing themselves and their (culture-specific) difficulty of referring directly to their illness (Dwairy, 2006). Note that incorporating artistic activities was not part of the adaptation process, but was initiated by the facilitators.

Culture-specific facilitators included adapted training, supported by research on the importance of cultural competence practice for successful implementation of culturally-adapted interventions (Al-Makhamreh et al., 2012; Castro et al., 2010; Samson & Roger, 2014), and more specifically, on the acquisition of Arabic terminology (Whaley & Davis, 2007). The latter was particularly important in the Israeli context where Arab practitioners study in Hebrew universities and usually train with Jewish peers using professional materials in that language.

The second culture-specific facilitator was the adapted manual, consistent with the general recommendation to provide therapy in the client's language (Barrera et al., 2013; Soto et al., 2018), as well as to use psychoeducational strategies in Arab culture (Natur, 2019). The manual contents were not only translated into Arabic, but also adapted to Arab society. This adaptation is critical to the Arabs in Israel, who still tend to perceive mental illness differently than the Jewish majority does (Central Bureau of Statistics, 2018; Daass-Iraqi et al., 2019).

Third, following the spiritual turn, addressing spirituality is now considered an ethical duty of professional therapy (Milner et al., 2019). Its importance is evident in the manual's use of Islamic contents as complementary to medication, rather than describing them as antithetical to “scientific” treatment. Ignoring spiritual content could delay and even derail the entire recovery process (Das et al., 2018; Gehart, 2012; van Weeghel et al., 2019). Hickey et al. (2019) consider religion a source of mental strength and individuals’ spiritual beliefs more generally are often a significant protective factor that can promote coping or recovery (Vader, 2006). In the present context, this is critical given that Islam is a minority religion in Israel.

Fourth, there is growing global awareness of the importance of family involvement (Ward et al., 2017). Similar to religion, the adaptation of IMR acknowledged the centrality of the family in Arab society (Roe et al., 2019(. As suggested by Gearing et al. (2013), home visits are particularly effective in engaging the family and in empowering clients and understanding their daily circumstances. Note that whereas family engagement should always be sought, it should be pursued with caution. Some participants did not want their family to participate in the process, perhaps due to the modernization of Arab society, which affects the younger generation more strongly. Given that complexity, it would be inadvisable to recommend family involvement in every case, but only based on an assessment of each particular situation.

Universal barriers include having to meet needs beyond IMR due to the shortage in and low usage of welfare services in Arab society, due to discrimination and social stigma, as well as social and self-stigma among the group participants (Daass-Iraqi et al., 2019; Roe et al., 2019). Another barrier is the difficulties that some clients experienced in reading and writing, which raises the question whether the adaptation should include further adjustments. In the implementation process, in addition to the use of art and role-plays, the facilitators coped with this issue by dividing their groups into subgroups, with literate group members helping the illiterate. In some cases, they also informed others involved in treating illiterate group members so that they would help them with the IMR homework. Finally, self-stigma is a universal barrier, but it is much stronger in collectivist societies such as Arab society in Israel (Abdullah & Brown, 2011).

Only one culture-specific barrier was found: the family. This reinforces the claim that families may delay recovery by acting as stressors, displaying stigma and lack of understanding (Aldersey & Whitley, 2015). Some families acted as barriers by being too involved, lending support to recent efforts to develop interventions that have positive impact on the entire family (Gelkopf & Roe, 2014).

Limitations and future directions

When evaluating the acceptability, feasibility, and clinical utility of a program, it is important to get the view of all stakeholders (with family members being a crucial one). The current study, however, focused only on Arab practitioners who had delivered the culturally adapted IMR groups.

Second, our participants wanted to highlight facilitators, which is also a cultural tendency. In addition, being an innovative program, it may have stood out in our participants’ experience, as compared to their previous experience. Future studies could avoid these biases by emphasizing in the interviews the need to hear about barriers as well.

Third, regarding generalizability, our conclusions are not automatically applicable to other Arab societies in countries where Arabs are the majority, nor to other ethnic minorities in Western countries. Nevertheless, they can certainly inform other efforts worldwide.

Finally, our program implemented formal adaptations in relation to Islam. Christian and Druze Arabs also participated and adjustments were made accordingly in the sessions. In the future, the manual will include formal adaptations to those populations as well.

Implications for research, policy, and practice

Our findings lend support to the notion that to implement culturally adapted interventions, care must be taken to preserve their core principles, which are often Western, as well as to introduce culture-specific elements (Daass-Iraqi et al., 2020). There is reason for optimism as, overall, the findings suggest that cultural difference may be overcome in implementing EBPs developed in the West, given that multiple culture-specific facilitators have been identified, whereas only one barrier was culture-specific. Our findings also suggest that Israeli universities should provide culturally sensitive tools to Arab students who would be working within their society in the future.

Specifically, we identified an important factor of family over-involvement. Future studies need to expand its role. Most world societies are traditional, and there is extensive literature on the importance of family involvement (Dausch et al., 2012). Therefore, when developing EBPs, the family's role must be addressed in all cultural contexts. In future training and implementation, the home visits initiated by the participants should become integral to the program. We also recommend creating a toolkit of nonverbal activities for Arab facilitators to use with clients.

On the policy level, we recommend increasing the resources allocated to welfare services in Arab society in Israel. Funds should be allocated to enable welfare workers to work with the families of people with SMI, including home visits, and to enable this program and others to include a family psychoeducation element.

Finally, the present study contributes to the literature by focusing on facilitators and barriers on the organization and community levels, rather than substantiating culturally adapted EBPs exclusively on the level of the individual client (Cabassa & Baumann, 2013).

Conclusion

This study is the first to examine facilitators and barriers in implementing a culturally adapted version of the IMR—or any EBP for that matter—for Arabs with serious mental illness in Israel. The culture-specific facilitators included adapted training and more specifically, the use of Arabic terminology, as well as the adapted manual. Only one culture-specific barrier was found—family over-involvement. The fact that we identified more facilitators than barriers attests to the rehabilitation workers’ need for a culturally adapted intervention to use in their daily work. Faras, an Arab social worker, expressed the general sentiment by saying: “For us, this instrument was like air to breathe.”

Footnotes

Acknowledgements

This article is part of the first author's requirements for a PhD. I am grateful to the Laszlo N. Tauber Foundation for its generous scholarship support. I am also indebted to our partners in the cultural adaptation process and the implementation from Ministry of Health, Ono Academic College, and JDC Israel.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sara Daass-Iraqi

Sara Daass Iraqi, PhD, is an occupational therapist with a bachelor's and master's degree in occupational therapy from Tel Aviv University, and a PhD from the Department of Community Mental Health, University of Haifa, Israel. Her published works focus on illness management and recovery in Arab society in Israel, particularly the process of implementing cultural adaptation and its effects on the rehabilitation and recovery of people with severe mental illness. Nowadays she is a lecturer in the Department of Education and Director of Development in the School for Mental Health Rehabilitation at Ono Academic College. In addition, Sara is a supervisor in mental health rehabilitation.

Paula Garber-Epstein, MSW, PhD in Community Mental Health, is a lecturer on mental health in the Bob Shapell School of Social Work, Tel Aviv University. Dr. Garber Epstein researches mental health services for youth with first psychosis, the implementation of recovery intervention, and peer support services. Her published works focus on mental health intervention research, adaptation of recovery interventions for minority populations, and peer support services.

David Roe, PhD, is a licensed clinical psychologist, Professor at the Department of Community Mental Health, University of Haifa, Israel, and Affiliated Professor at Aalborg University, Denmark. His research focuses on the psychosocial processes of recovery from serious mental illness, stigma, patient reported outcome measures (PROMs), and the evaluation of interventions and services. His research has been funded by several local and international sources, including the NIMH, Israeli Science Foundation, Israeli Ministry of Health, Israel National Institute for Health Services Research and Health Policy, the Israeli National Insurance Institution, and the Tauber and Rich foundations. Dr. Roe has published extensively and serves as associate editor at the Psychiatric Rehabilitation Journal, Journal of Mental Health, BMC Psychiatry, and Israel Journal of Psychiatry, and on the editorial board of American Journal of Psychiatric Rehabilitation, Stigma and Health, Journal of Clinical Psychology, and Psychosis and Social Welfare (Hebrew).

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