The impact of migration on the mental health of the Beta- Israel (the Ethiopian Jewish community in Israel). Anne-Marie Ulman MD Beer Yaakov Mental Health Center Sackler Faculty of Medicine, Tel Aviv University

Centre Georges Devereux Universite Paris 8 Saint-Denis Universite Paris 8 Saint-Denis

The Beta-Israel The Ethiopian Jewish Community in Israel

Todays community: members 1984: Operation Moses 1991: Operation Solomon

Ethiopian-Jewish culture -Lived in the highland villages in the north- western regions of Gondar and Tigray -Tribal cultural model (the Shmaglotchs law) -Patriarchal family organization -Oral transmission of the tradition

History -18 th century: James Bruce uncovers the existence of the falasha -Prof. Joseph Halevy (1867): Establishment in Abyssinia before the development of the Talmud as cause of the difference in rites between Beta-Israel and the rest of the Jewish Diaspora Establishment in Abyssinia before the development of the Talmud as cause of the difference in rites between Beta-Israel and the rest of the Jewish Diaspora - Dr. Jacob Faitlovitch: Prof. Halevy follower, dedicated to the cause of the Ethiopian Jews, promoter of their education

Literature review

Psychopathology among Jewish Ethiopians (I) Arieli & Aycheh, 1991 Two major sources of psychological distress: - The trauma of the journey: Comparable to the experience of Holocaust survivors Inability to respect burial tradition Guilt feeling toward the family left behind The interface with the Israeli reality: Control of Hebrew Economic status Place of residence Religious issues

Somatization not yet understood as an expression of psychological distress Arieli & Aycheh, 1991

Psychopathology among Jewish Ethiopians (II) Arieli & Aycheh ,3% anxiety 28,4% depression 29,4 % somatization 11% psychosomatic activity 28,8% sleep disturbance, nightmare

The culture shock was directly responsible for the psychopathology found among the Beta-Israel

acculturation stress the result of the conflict between the need to cope with new values of the host culture and the need to stay faithful to traditional cultural values of reference.

The acculturation stress of the Ethiopian community is among the highest that any community experienced during the immigration process. Arieli & Aycheh 1991 The acculturation stress of the Ethiopian community is among the highest that any community experienced during the immigration process. Arieli & Aycheh 1991

Somatization - Bodily expression of an emotion or physical illness - Difficult encounter with the Israeli medical system - Youngmann (1999): Generalized unlocalized pain and pain localized typically in the head, heart and stomach are common metaphorical somatic complaints

Other ways of coping with distress (I) - Brief reactive psychosis (Grisaru 2003) (Grisaru 2003) - Brief psychotic episodes appeared instead of classical PTSD (Grisaru 2003) - Eating arrest (Gady Ben-Ezer, 1990) - Dissociative disorders among the Ethiopian origin adolescents (Ratzoni 1993)

Other ways of coping with distress (II) - Adolescents dissociative reaction could be connected to the Zar spirits (Ratzoni 1993) 10 to 12% of the patients presented a Zar Spirit link clinical picture (Arieli 1994, Grissaru 1997)

Zar Syndrome: Cultural norm or pathology?

The Zar Spirit

The Zar Spirit (I) Mythology (Kahana, Nudelman, Edelstein) - Common origin to humans and spirits in Garden of Eden -The Zar spirits are the descendants of Eves hidden children who were given the power to possess their human relatives -Parallelism between human and magic world

The Zar Spirit (II) - Zar spirits cause specific physical and mental afflictions - The mental troubles attributed to the Zar are considered as curable by negotiation - Wadaja: monthly gatherings scheduled according to the Ethiopian calendar

The Zar Spirit (III) Once the Zar rides his horse he never gets off his back really (Ethiopian proverb)

The Zar Spirit (IV) - A balazar is someone afflicted by a Zar spirit - Not very Balazar is a Zar-Doctor - Zar spirits transmitted over 7 generations - Zar-clan: rival structures hierarchy organized (Zar-Doctor, principal adepts, afflicted) - Treatment failure are viewed as an admission of human inferiority

The Zar Spirit (V) The Zar afflicted are not considered gods or even supernatural, but rather humans altered by the divine in a mythical time. Zar is a way of dealing with invisible forces, fortune, misfortune, illness and well- being (Edelstein 2000) (Edelstein 2000)

The Zar Spirit (VI) Zar spirits, as well as the Ethiopian Jews with whom they immigrated, are still immersed in a transition process searching for their own niche on their way to integration in their new homeland (Nudelman, 1995)

The suicide issue (I) (Shoval and al. 2007, Arieli 1996 ) 1984: suicide rate among the Beta-Israel : 25:100,000 (6:100,000 national suicide rate). 1986: suicide rates sevenfold higher among the Beta-Israel than the natives 1991 – 1992: 3 times higher.

The suicide Issue (III): A survey Conducted by Means of a Psychological Autopsy (Arieli & al., 1996) High risk factors: - Young married man with family conflicts - Young married man with family conflicts - Internalization of aggression - Internalization of aggression - Depression - Depression - No communication of suicidal intentions - No communication of suicidal intentions

The suicide issue (IV): How can this phenomenon be understood? - Suicide of Samsonic nature (Arieli 1996) - Epidemic wave because of a traumatic transculturation process (Durst 1993) - Prejudice, discrimination and consequent social seclusion (Ringer 2005) - Cultural misunderstanding by professionals: possible cause for under-diagnosis and under-treatment (Shoval 2007) - Adolescents suicide: result of great stress in combination with the learning of a new language from Israeli counterparts.

Group Counseling and Psychopathology Across the Cultural Divide: The case of Ethiopian Jewish Immigrants in Israel (Ben-Ezer,2006) - Cultural competence - Cultural code - Parallel process - Mutual Creative Space

Metuku

Conclusion

The suicide issue - Acute problem - Inter-disciplinary work - Prevention strategy

The therapeutic issue (I) - What do we do in front of concepts that belong to another cultural system? - How do we create dialogue with systems of reference that are not ours? - The capacity to work with cultural concepts unfamiliar to all the team is a crucial further development in the field of trans-cultural psychiatry

The therapeutic issue (iI) By trying to conceptualize otherwise we discredit a system on the basis of cultural difference (Edelstein 2002). A patient without any code of reference cant express his psychopathologic suffering. It is why the process of cultural referent identification is fundamental (Tobie Nathan 1996)