Cultural Adaptation of the Illness Management and Recovery Intervention Among Israeli Arabs

Illness management and recovery (IMR) (4) is an evidence-based practice (EBP) aimed at helping people with serious mental illness make progress toward recovery goals and acquire the knowledge and skills to better manage their difficulties. It was developed on the basis of five strategies found to be effective from a review of 40 empirical studies: psychoeducation, behavioral tailoring for more effective use of medication, relapse prevention, social skills training, and coping strategies. IMR has been implemented in several countries, including Israel, where a controlled trial found it effective in improving knowledge, daily functioning, hope, and quality of life; advancing progress toward personal goals; and enhancing ability to cope with stress and symptoms (4). Recently, the Hebrew version of IMR has attracted growing attention among Israeli Arab mental health practitioners, who noted its potential usefulness for Arab people with serious mental illness in Israel. They also recognized that the intervention required cultural adaptation. Whereas the core elements of IMR were relevant to Arab society in Israel, two barriers affected the intervention’s implementation: the use of Hebrew and the irrelevance of many of the examples of illness- and coping-related experiences and some of the self-management strategies within Arab society. These barriers emphasized the need to develop a version that would be culturally adapted to Arab culture and take into consideration Arab society’s communication codes, local rules and traditions, social structure, religious beliefs, and explanatory models of mental health and illness (5).

Although it is modernizing, Arab society in Israel largely remains patriarchal, with the family playing a central role. When someone develops a mental illness, the family supports and helps him or her and often makes most of the treatment decisions (3). Barriers to service utilization include lack of culturally adapted services, lack of awareness of the right to treatment, as well as stigma and lack of information about mental illness (5). Consequently, Arabs with serious mental illness and their family members sometimes turn to religious authorities for treatment, believing the illness is related to insufficient devotion. Together, these processes hamper the opportunity to gain social support, which is widely recognized as crucial for recovery (3, 5).

The adaptation process began by establishing a steering committee to coordinate collaboration among key stakeholders: IMR and Arab rehabilitation experts, the Ministry of Health, the Ono Academic College National School of Rehabilitation, and the Joint Distribution Committee–Israel Division of Disabilities and Rehabilitation. The process was informed by three theories. The first theory was the heuristic framework for cultural adaptation of interventions (6). According to this framework, cultural adaptation should proceed in the following four phases: information gathering, preliminary adaptation design, preliminary adaptation testing, and adaptation refinement. We have not yet completed the fourth phase, but we have conducted a study on the effects of the adapted intervention and barriers and facilitators to its implementation, which will form the basis of future refinements.

The second theory was Bronfenbrenner’s ecological theory (7), which proposes that to promote change, therapists must work within the broader cultural context. Accordingly, one of the main cultural adaptations of an intervention is to engage the family—as well as other cultural elements that are essential to participants’ acceptance of the treatment—into the treatment process. Third, our process was informed by the ecological validation model, which stresses the need to maximize client-treatment match in terms of language, persons, metaphors, content, concepts, goals, methods, and context (8) (Table 1).

Throughout the adaptation process, we maintained a balance between recommended adjustments and the core components of the original IMR. Fidelity has been maintained by retaining the content and chapters of the curriculum of the original intervention. The revisions involve changing examples and expanding the psychoeducational material, including religious explanations about coping with mental illness. Finally, resources about stressors and coping have been added or revised to ensure relevance to the lifestyle in Arab society in Israel. The adaptation involved four stages.

Out of the 102 participants who began attending the 13 groups, 77 participated in the entire intervention (26 weekly sessions), which illustrates its feasibility. The IMR practitioners provided valuable ongoing feedback during the 9-month supervision, offering useful comments, for example, about the positive impact of incorporating art activities and suggestions for future revisions in the manual. Finally, upon completion of the intervention, interviews with 14 IMR practitioners and 19 consumers were carried out, providing additional valuable feedback, which will be used to guide the ongoing dynamic process of cultural adaptations.

Cultural adaptations of mental health EBPs are attracting growing interest, and efforts are underway to make interventions developed mostly in high-income countries (1)—and found to be effective—accessible and culturally relevant to diverse populations, cultures, and minority groups worldwide. This column focuses on the process of creating a cultural adaptation of IMR for Israeli Arabs. The process was challenging and involved multiple dilemmas, including deciding how to best involve key community stakeholders, such as religious leaders and families, and to incorporate religious beliefs and family values and traditions.

Family members were granted a much more central and structured role in the Arabic version of IMR. Although they did not participate regularly in the actual intervention, family members attended separate meetings with instructors. The adaptation focused on encouraging family involvement and strengthening ties between family members and mental health professionals to help families better support their loved ones. To facilitate this process, we developed an IMR manual in Arabic for the families, which aimed to help improve communication with and understanding of their loved ones’ experience with mental illness and to help families develop ways to better support the recovery process. Importantly, this focus did not distract from the core components of the intervention but rather added to and supported them.

The adaptation also involved identifying and addressing practitioners’ needs to acquire specific skills related to engaging, incorporating, and working collaboratively with key stakeholders who play important roles in the recovery process. Finally, we added explanations about spiritual strategies for coping with mental illness within the context of religious belief. A growing literature suggests that religion and spirituality contribute to positive coping with mental illness (9). Nevertheless, religion can also have a negative influence, particularly when it replaces or delays effective treatment (10). It was therefore important to stress that while spirituality may be very helpful for many, it should not replace effective, evidence-based treatment.

Culturally adapted interventions can contribute significantly to helping people with mental illness from diverse cultures and social groups. Our pioneering effort to create and implement an Arabic version of IMR and to train personnel in its application has helped shift clinical practice from “intuition based” to structured, evidence-based, and culturally sensitive. The process can be seen as a test case of cultural adaptation of an EBP for Israeli Arabs that might inspire and inform future efforts to create culturally sensitive adaptations of EBPs. Integrating research evidence and cultural contexts is crucial to facilitate equality and access to effective treatment. We hope that, in the future, the right to receive culturally adapted mental health services will be recognized in Israeli law and that resources will be allocated for this important purpose.