Cultural competence in multi-family psychoeducation groups: The experiences of Russian-speaking immigrant mothers of adults with severe mental illness

Abstract

The successful integration of cultural competence with evidence-based practices in mental health services is still limited for particular cultural populations. The current study explored culturally adapted family psychoeducation intervention for immigrants from the former Soviet Union (FSU) in Israel who care for a family member with severe mental illness (SMI). Semi-structured in-depth interviews were conducted with 18 immigrant mothers about their experience of taking part in Russian-speaking multi-family psychoeducation groups (MFPGs). Qualitative content analysis revealed five salient processes and changes that participants attributed to their engagement in the intervention: 1) from a language barrier to utilization of and satisfaction with services; 2) from a lack of information to acquiring new mental health knowledge; 3) from harboring a family secret to exposure and sharing; 4) from social isolation to cultural belonging and support; 5) from families blurring boundaries to physical and emotional separation. The results showed that these changes—linguistic, cognitive, emotional, socio-cultural and relational—improved family coping and recovery. Implications for cultural adaptation of family psychoeducation for Russian-speaking immigrants are discussed.

Introduction

Following the collapse of the Soviet regime in the early 1990s, millions of Russian-speaking citizens emigrated to Western countries. To date, more than 7.5 million Russian-speaking first- and second-generation immigrants live in Israel, the US, Canada, and Germany (Kostareva et al., 2020). Just in Israel, over 1 million immigrants arrived from the former Soviet Union (FSU) between 1990 and 2015, enlarging the general population by about 16% (Sheps, 2016).

Whereas some immigrant groups from the FSU have adjusted well to the Western countries, others have shown elevated levels of psychological distress, somatization, and mental disorders (Jurcik et al., 2013; Mirsky et al., 2008; Ristner et al., 2000). For example, in epidemiological studies conducted in Israel, FSU immigrants were found to be at about 1.5 times greater risk for developing psychotic, affective, and anxiety disorders than native-born Israelis (Mirsky et al., 2008; Weiser et al., 2008). At the same time, FSU immigrants display relatively negative attitudes toward mental health services and utilize them at low levels (Ristner et al., 2000; Shor, 2006). Additionally, FSU immigrants who have received mental health services and treatments report low levels of satisfaction (Dolberg et al., 2019; Knaifel & Mirsky, 2015b).

Researchers have explained these mental health disparities by noting that FSU immigrants experience more stress and social adversities due to adjustment difficulties in the host country, and also demonstrate lower mental health literacy (knowledge and beliefs about mental disorders) in comparison with the local-born population (Nakash et al., 2020). In addition, the lingual and cultural barriers make it difficult for them to seek help and receive the desired services; these barriers include communication difficulties, high levels of social stigma surrounding mental illness, and suspicion and distrust of the system (Knaifel & Mirsky, 2015a; Shor, 2006). Such negative attitudes toward mental health services have also been shown to be related to the political abuse of psychiatry in the Soviet Union (van Voren, 2010), as well as a limited knowledge of Western mental health care and treatments (Dolberg et al., 2019).

Implementing culturally competent care has become a central strategy over the last two decades to reduce ethnic disparities (Kirmayer, 2012b). This type of care aims to make health care services more effective and accessible for diverse ethnocultural communities and their special social, cultural, and linguistic needs. Cultural competence is especially important, albeit challenging to implement, in the context of evidence-based interventions in mental health care. While evidence-based interventions aim to produce accurate and generalizable knowledge, they may sometimes disregard the subjective experiences, cultural values, and life contexts of patients and their families (Good & Hannah, 2015; Kirmayer, 2012a).

One of the most vital evidence-based interventions in mental health care is family psychoeducation. This intervention, developed by Falloon and colleagues in the early 1980s (Falloon et al., 1984), has become one of the leading practices utilized in working with families who care for relatives with severe mental illnesses (SMIs) (which comprise schizophrenia, bipolar affective disorder, and major depression). Psychoeducational interventions have proven beneficial both for individual families and for multi-family groups (Dixon et al., 2001; McFarlane, 2002).

Multi-family psychoeducation groups (MFPGs) include a series of weekly meetings with family caregivers (usually 12–15 sessions), led by a mental health professional. The goals of MFPGs include: imparting essential knowledge about mental illnesses, encouraging families to engage problem-solving coping, decreasing family members’ expressed emotions (e.g., criticism and over-involvement), and establishing a support network. In a series of studies, this intervention has been shown to help families reduce the stress, burden, and stigma that come with caring for a relative with an SMI (Dixon et al., 2001; McFarlane, 2002). The MFPG has been shown to help decrease symptoms and psychiatric hospitalizations among persons with SMIs, as well as to improve their functioning and recovery (Dixon et al., 2001).

In recent years, as part of the goal of increasing cultural competency in mental health services, attempts have been made to adapt family psychoeducation programs to different cultural contexts, such as Chinese and Hispanic minorities in the US (Hackethal et al., 2013; Kung, 2016a) and Vietnamese immigrants in Australia (Bradley et al., 2006). These studies have demonstrated the effectiveness of psychoeducation interventions in addressing the needs of families from different cultural backgrounds. However, further studies are needed to examine the impact of MFPGs on immigrants and ethnic minorities in non-English-speaking countries.

Context and aim of the current study

In Israel, which is a multicultural country, there have been institutional attempts in recent years to adapt evidence-based mental health practices to the immigrant and ethnic minority populations (Daass-Iraqi et al., 2021; Knaifel & Mirsky, 2015b). Despite the fact that MFPGs are widely popular and well-evidenced in Israel (e.g., Levy-Frank et al., 2012), studies examining the effectiveness of family psychoeducation for immigrant caregivers in general, and for FSU immigrants specifically, remain lacking.

One of the main features of FSU immigrants in Israel is their high level of education and professional experience in the labor market, which helped many of them to integrate into Israeli society (Remennick, 2012). However, their tendency to preserve lingual and cultural characteristics of their country of origin (Kostareva et al., 2020), as well as a tendency toward low mental health literacy and high levels of emotional distress (Dolberg et al., 2019; Nakash et al., 2020), demands that the implementation and evaluation of culturally adapted interventions be expanded.

This article is part of a larger qualitative study investigating experiences among FSU immigrants in Israel who care for a family member with an SMI. The aim of the current study was to explore the experiences of Russian-speaking mothers of adults with SMIs who participated in culturally adapted MFPGs. The use of a qualitative approach in this study allowed for a more complex and nuanced evaluation of cultural competence practice from the perspective of immigrant caregivers, a group that is known to be hard to reach. The main study questions were: (1) What are the salient processes and changes experienced by participants in Russian-speaking MFPGs?; (2) Which components of Russian-speaking MFPGs are most essential to address the participants’ unique needs?

Method

Participants

Participants were recruited from community-based family counseling centers (FCCs), which assist families of individuals with mental health problems; these centers are funded by the psychiatric rehabilitation unit of the Ministry of Health in Israel. The criteria for inclusion in the study were as follows: (a) cares for a family member with a diagnosed SMI, who has been determined to have at least 40% disability (characterized by notable social and vocational impairments) by the psychiatrist-led medical committee of Israel's National Insurance Institute; (b) an FSU immigrant who emigrated to Israel after 1990; (c) living with, or having at least weekly contact with, a family member with an SMI; (d) participated in a Russian-speaking MFPG.

Eighteen mothers of an adult son or daughter with an SMI participated in the study. Participants ranged from the age of 49 to 71 (M = 60.5). In 67% of the families, the participants were single mothers (divorced or widowed). Most of the participants immigrated to Israel in the 1990s (61%), and the remainder immigrated after the year 2000 (39%). Participants immigrated from various regions of the FSU: Russia (n = 10), Ukraine (n = 4), Belarus (n = 2), and Middle Asia (n = 2). The average number of years since arrival in Israel was 18.1 (range: 5–25 years). Most of the participants had an academic degree (89%).

According to the demographic characteristics provided by the mothers, most of the adults with SMIs were male (72.2%). The psychiatric diagnoses included: schizophrenia (n = 13), bipolar disorder (n = 3), and major depression (n = 2). The average number of years since receiving a psychiatric diagnosis was 14.5 (range: 3–34 years). In most cases, the sons or daughters with SMIs lived in a joint residence with their family (72.2%), while the others lived in community rehabilitation housing such as hostels or assisted living facilities.

Study procedure

This study was carried out in two FCCs in Israel's different geographical regions that, alongside providing original family psychoeducation, offered linguistically and culturally adapted interventions for FSU immigrant caregivers. The FCCs were located in two Israeli cities with a high concentration of Russian speakers (21–26% of city residents) of low and middle socio-economic status (Sheps, 2016). Interventions were carried out by three Russian-speaking mental health professionals who had experience working with FSU families of persons with SMIs.

The participant recruitment process was carried out by the mental health professionals who worked in FCCs. They identified potential participants who met the inclusion criteria and subsequently informed them of the study. If a family caregiver was interested in participating, the professionals provided her with my contact information to obtain a more detailed explanation of the study. Twenty participants from four MFPGs agreed to participate in the current study (40–50% of participants from each group); a total of 18 participants met the study's inclusion criteria.

The research instrument used was a semi-structured in-depth interview. The first part of the interview focused on the spontaneous narrative of the participants (“Tell me the story of your family”). In the second part of the interviews, participants were presented with more specific questions about their experiences in the Russian-speaking MFPG. The questions were taken from the Narrative Evaluation of Intervention Interview (NEII) (Hasson-Ohayon et al., 2006). This tool can be utilized to evaluate the subjective experiences of participants retrospectively, including MFPG (see Levy-Frank et al., 2012). The open-ended questions asked participants to describe the outcomes and processes of the group intervention, for example: “Please describe what the intervention contributed to you”; “What changes, if any, took place during participation in the intervention?”; “How does this intervention differ from other interventions that you have attended in the past?”; “What did the group leader who delivered the intervention do that helped you?”; “What components of the intervention were helpful?”.

Each interview was conducted individually, lasted between one and two hours, and took place either in the participant's home or at the FCC (whichever the participant preferred). The interviews were conducted in Russian—my own mother tongue and that of the participants. The interviews were audio-recorded, transcribed, and then translated into Hebrew/English.

The institutional ethics committee at Ben-Gurion University of the Negev and the Ministry of Health approved the research. Informed written consent was obtained from all participants prior to beginning the interview. To preserve confidentiality, the names of the participants, as well as any other personal information that might identify them or their family members, were either changed or deleted from transcriptions and analyses. Participants were informed that they could withdraw from participation at any time and for any reason, without incurring negative consequences.

Data analysis

Data were analyzed using qualitative content analysis (Hsieh & Shannon, 2005). The first stage of analysis involved a process of open coding for each interview. Line-by-line coding was performed, and preliminary themes were identified. During the next stage, I identified significant codes and themes relating to the intervention process and its consequences. In this phase, themes were mapped more precisely, and “entry criteria” for each theme were established. Factors such as saliency and frequency of mention were used to determine the significance of the themes. At this point, some of the themes were renamed and reorganized. The comparison of themes across cases was achieved through repeatedly moving between the individual interviews, common themes across interviews, and prior theory. Data saturation was reached when no more new codes or themes emerged.

To ensure the trustworthiness of the analysis, several steps were taken. First, I consulted with another experienced qualitative researcher, who served as an external expert, commenting on and analyzing the data and emerging themes (Creswell, 2007). Second, the research design, data collection procedures, data analysis, interpretation of data, and organization of findings were described in detail. Third, the analysis process and subsequent results were both presented to, and discussed with, the mental health professionals who led the Russian-speaking MFPGs. They remarked that the findings resulting from the data analysis accurately represented their experiences as leaders of these groups.

Reflexivity

The influence of my own bicultural and professional identity as an FSU immigrant and clinical social worker who works with immigrants with SMIs and their families is reflected in my choice of topic and research population. As such, I have a close personal and professional connection with the research topic. This familiarity placed me in an “insider” position with respect to the participants and facilitated recruitment as well as my ability to build rapport with participants relatively quickly during the interviews. In addition, I was able to apply my personal and clinical experience with FSU immigrants to the analysis process, in such a way that enabled me to recognize cultural nuances present in the data. Unlike the participants, I do not have experience as a caregiver for a family member with an SMI, and I am a younger male (whereas all of the participants were middle-aged women). This “outsider” status helped some participants feel more at ease, as they felt as if they were in a position of authority in having accumulated knowledge and experiences that I had not, which subsequently led them to be more open in sharing their insights and experiences.

Results

The qualitative content analysis revealed five salient processes and changes that immigrant mothers experienced as a result of their participation in the Russian-speaking MFPGs: 1) from a language barrier to utilization of and satisfaction with services; 2) from a lack of information to acquiring new mental health knowledge; 3) from harboring a family secret to exposure and sharing; 4) from social isolation to cultural belonging and support; 5) from families blurring boundaries to physical and emotional separation.

From a language barrier to utilization of and satisfaction with services

The fact that the MFPGs were offered in participants’ native Russian language helped them to overcome the typical linguistic barrier as it enabled non-Hebrew-speaking caregivers to both participate in and benefit from the group sessions. Most participants (n = 13; 72%) stated that they were not fluent Hebrew speakers and needed linguistic mediation even many years after their immigration.

I have been in the country for 20 years, but the language is still difficult for me. I kept working with Russians and I didn’t have a high level of Hebrew, which is why I’m having a hard time. I tried to approach a social worker, but they mostly speak Hebrew and I don’t understand anything so I was very happy to have an organized Russian-speaking group here. (Eva)

Some participants said that they had tried to apply to an FCC in the past and to participate in groups but, due to language barriers, they were unable to receive satisfactory service.

In the beginning, I came there [FCC] and no one understood me. I explained to them that I want to discuss issues … and preferably in Russian, because even if I can communicate my problems in Hebrew, I won’t understand what they tell me … and at that time I was unable to receive this help because there weren’t any Russian-speaking providers. Only after a year and a half did they contact me when a Russian-speaking worker arrived, and she invited me to join the group. (Marina)

Participants indicated that the need to receive help in the Russian language stems not only from objective linguistic difficulties but also from an emotional need. Some of the participants who were fluent Hebrew speakers also described their preference to communicate in Russian in stressful and crisis situations: “When we began to participate in the group, we preferred Russian. I didn’t care that much, but my husband said that he wants to discuss this extremely sensitive matter only in Russian, even though he knows Hebrew” (Daria).

The additional advantage of a Russian-speaking group was the bond that was formed with the group leader, and her ability to serve as a lingual mediator between caregivers and the mental health providers of their children with SMIs:

I can’t converse with any of her staff members because they are all Hebrew speakers and for me this is a real problem and barrier. I even asked the group leader to contact the people working in protected housing so that I could understand what's going on there. So, she helps me out a lot in these situations because I can rely on her. (Nelly)

From a lack of information to acquiring new mental health knowledge

Participation in the group contributed to a change in the mothers’ cognitive understanding, as it became a space in which they learned and acquired vital knowledge that reshaped their attitudes toward the mental health field. Eighty-three percent of mothers (n = 15) stated that, until they began to participate in the group, they severely lacked information regarding existing services and rights in the mental health field. They felt that this situation hindered the recovery processes of their loved ones and intensified the burden imposed on them as family caregivers:

I want to say that we lack information … there is almost no information available in Russian. Not in the hospital, not about the rehabilitation services, not about our rights … And I feel that we have a real hunger for information. It's absolutely a real hunger, because I can’t find anything, I don’t know who to turn to, and I don’t know about the existing options for us. (Marina)

Some participants emphasized that the educational and directive nature of MFPGs was suitable for the cultural background of FSU immigrants: “‘Paint something.’ ‘What are your associations?’ ‘Why did you choose this card?’ It's not for us, it does not fit our mentality … We need something more concrete and we receive it here” (Bina).

The educational nature of Russian-speaking groups enabled the participants to acquire knowledge, tools, and vital information regarding mental illness and relevant treatments.

The group leader described very clearly the situation surrounding the children, the illnesses, and the parent caregivers. Because there is very little literature available in Russian, I really lacked information. I would like for the families to have clear information because it helps us to understand the illness symptoms and to deal with them more correctly. (Nina)

Some of the essential information that the group participants were initially exposed to was regarding progressive community rehabilitation services that did not exist in the FSU: “After I began participating in this group, I heard that there is a community-based rehabilitation and that a mental health instructor can be arranged … this is something that I only discovered here” (Lydia).

The knowledge that accumulated over the course of the group meetings empowered the participants and generally improved their sense of control, security, and assertiveness as immigrant caregivers when dealing with the system in order to utilize rights and new services:

When I came to his social worker at the clinic, I immediately showed him what the counselor from the FCC printed about this or that new service, and he [the social worker] was surprised. He pretends that he doesn’t know, or perhaps the information reaches the group before it gets to him, I don’t know. But what matters is that we know what, when, and from whom we need to request services. The knowledge gives us a lot of power. (Bronislava)

From harboring a family secret to exposure and sharing

Group participation gave mothers a space to vent and changed how they coped with mental illness. They changed from regarding mental illness, and its accompanying stigma, as something that had to be concealed, to sharing and being open about their experiences. Before participating in the group, mothers’ knowledge and attitudes regarding mental illness stemmed mainly from stereotypes and stigmatic opinions that they developed in the FSU:

Over there, by us [in the FSU], it [the illness] was a terrible shame and people would keep away. Like venereal disease—God forbid that someone should know … here, because of our Soviet mentality, I didn’t tell anyone, and since I didn’t tell anyone, I couldn’t expect help from anyone for many years. (Bina)

The fear of rejection and discrimination, due to mental illness, in their country of origin caused them to internalize the public stigma and react with withdrawal and caution even after they immigrated to Israel. In Svetlana's opinion, an especially pronounced stigma was prominent among intelligent and well-educated Jewish-Russian families that she met in the group:

I remember that, in the beginning, people in the group were very closed off [when it came to talking about mental illness] because of the stigma. People think it's something that you should be ashamed of, and this is all due to the mentality and attitudes that we internalized over there. People think that things like this don’t happen in intelligent and refined families. This mentality can be seen when parents come for treatment and ask how it could be that this happened to us, we raised our son in the best way possible.

Most participants (n = 11; 61%) reported that, for them, the group was a unique space where, for the first time, they could share their family problems with others, problems that previously had been kept secret. The trust felt in fellow group members, one's personal openness to share, and the act of listening to each other's stories were significant factors in the emotional change that the participants experienced:

Thanks to the group I was able to speak about and share issues that I had never told anyone, and it was an emotional relief for me. It's important for me to have a place where I can unburden my heart, open up, and talk, because I feel much better afterwards. (Marina)

Some of the participants reported that, because of the definite cultural stigma in the Russian-speaking community and fear of rejection, they cannot share their problems with their friends, and that the group became the exclusively safe area for being open and sharing:

I don’t talk too much with the neighbors. Although half of my neighbors are Russian … You can’t tell anyone about this problem because no one will understand. But here they will understand. That's why people come to the group. Each one relates their problems and receives emotional support, and we also try to help each other at least by telling each other what I am telling you now. And what I am telling you, I don’t tell anyone. Because nobody cares. My other friends only want me if I’m happy. No one wants to hear painful stories. (Luba)

From social isolation to cultural belonging and support

Participation in the group helped to broaden the socio-cultural resources of the mothers who, due to their status as immigrants in a new country and parents (mostly single parents) of adults with SMIs, suffer from a sense of alienation and social isolation in their daily lives. For most of them (n = 13; 72%), participating in a Russian-speaking group was a unique opportunity to get to know additional families and to broaden their support network:

I feel that it undoubtedly widens my social circle, the fact that I go to the support group. Where else do I go? I don’t go anywhere else. And the fact that, due to my son's illness, I am forced to go out and communicate … and it helps me cope. (Natalia)

Beyond the social support received, the group meetings enabled the participants to experience, once again, a sense of cultural belonging. They felt belonging to a group of intelligent and educated people, which characterized their status in the FSU but had decreased after their immigration to Israel:

Beyond that, people that participate in the group belong to an older generation. There [in the FSU] they graduated from university, they had very respectable positions, but as life went on they found themselves in Israel. But here, they found themselves with nothing at all, and they feel very uncomfortable about it. At the family center they can at least speak to each other and feel at home. (Alexandra)

The sense of loneliness and cultural alienation was reflected in the responses of participants who had once participated in original Hebrew-speaking groups. Nina described the differences between the two groups, and emphasized the advantages of belonging to a group of people who share a common cultural background:

Once I participated in a group of Hebrew speakers and I left because it made me feel worse. Often, they would begin to argue and shout, and then I couldn’t manage to understand very much although I get along well in Hebrew. I’m a talkative woman, but there among the Hebrew speakers, I wasn’t able to say a word … Now in the Russian-speaking group it's more interesting and also the people are more intelligent. Here we feel closer to each other … (Nina)

The close ties that often formed among the group members continued outside the FCC, as the group members organized their own group gatherings. It appears that the common cultural orientation enabled participants to maintain these bonds, which subsequently enriched the mothers’ social life:

I am very grateful to the group because, thanks to them, I met people like me, and we became such good friends that today we are a clique … We now meet outside of the family center, we meet in our homes, we drink tea, we celebrate Russian holidays, we discuss various problems. (Luba)

From families blurring boundaries to physical and emotional separation

Participation in the group led to changes in the relationships that mothers had with their son or daughter with an SMI. In most cases (n = 11; 61%), the process they underwent in the group contributed to the creation of a renewed balance regarding boundaries, communication, and family dynamics that had been blurred following the outbreak of mental illness in the family and the immigration to Israel. The tension in the relationships, which escalated at times, is especially evident in the relationships between single mothers and adult male children. Vera described the transformation as one which used to be characterized by a state of fear and helplessness in her interaction with her son to one in which she was able to set clear and empathetic boundaries:

Before I began to participate in the group, I felt like I was in a vacuum. I didn’t know how to speak to him, when to give in to him, when to retreat, and when to confront him. I was like a hen … Let's say he calls me and begins to shout, I used to be silent and listen to him and afterwards I was exhausted and worn out for half a day. Now, at least on the phone, I can say: “Anton, don’t shout. If you go on like this, I’ll hang up.” I began to be brave, at least on the phone, and even at home, when he arrives and starts to become upset, I say: “Anton, let's sit down and discuss things.” (Vera)

The change that the group participants underwent was reflected in the warmer emotions they expressed toward adults with SMIs and the improvement in their communication with them:

The life that I had made me harsh and critical. And I was always making remarks and getting into arguments with him [my son]. Maybe I shouldn’t have acted that way with him. In the group, I realized that I should have related to him differently … with more, so to speak, warmth and love. Now I act differently towards him … and it has greatly improved our relationship … (Klara)

Other participants emphasized their tendency to be over-involved in the lives of their adult children. This tendency was especially evident in their dealings with the health system and encumbered the process of achieving appropriate boundaries within the family. The changes that resulted from the mothers’ participation in the group helped them realize the negative and hindering implications of being over-involved in the rehabilitation processes of their children:

Roslan [son with an SMI] made two attempts to enter the rehabilitation hostel. The first attempt was completely my fault. I used to intervene in what went on there, in the hostel, and I didn’t trust the staff. Can staff members manage to function with a mother like this who intervenes in every matter? Then I realized that I mustn’t intervene, and only then was the move to the hostel successful … And that's mainly due to the support that I received in the group. Before that, I was a completely different person. (Luba)

Another change that the group participants underwent related to their ability to set boundaries and create, at least occasionally, periods of time and rest for themselves. This change is reflected in their new ability to balance between the commitment and care for their children with SMIs on the one hand, and the commitment and care for their own personal needs on the other hand:

Thanks to the support group, my husband and I began to go out, because we hadn’t gone out at all before that … We forgot that we are a couple, we were only parents of an ill child and that was all. For many years we didn’t travel together anywhere and then we decided that we should give it a try. At first, we went for two days and we saw that he got along well by himself. Now we can even travel for five days and that's also thanks to the process we went through in the group. (Svetlana)

Discussion

The present study explored the experiences and processes of Russian-speaking mothers of adults with SMIs who participated in culturally adapted MFPGs. This study, which is the first of its kind, examined successful integration of cultural competence into an evidence-based intervention for FSU immigrant families in Israel. Immigrant mothers described their participation in the Russian-speaking MFPGs as a major resource that facilitated their ability to cope with mental illness in the family, and greatly contributed to the positive changes they experienced on an emotional, cognitive, socio-cultural, and relational level. These findings are congruent with the extensive research literature that has demonstrated the associations between participation in MFPGs and decreased sense of burden and stigma, along with an improvement in hope, coping strategies, and interpersonal communication (Dixon et al., 2001; Levy-Frank et al., 2012; McFarlane, 2002).

Beyond the overall benefits of family psychoeducation, the findings also showed that immigrant mothers who participated in Russian-speaking MFPGs benefited in some unique ways from these interventions: elimination of the language barrier, resulting in greater service use; acquisition of knowledge about Western mental health care; increased openness and sharing of experiences with others; decreased social isolation through feelings of cultural belonging and support exchanges. The findings are congruent with other studies that have identified the need to adapt evidence-based psychoeducational interventions to the lingual and cultural background of the families, and thus to make them more accessible and effective (Hackethal et al., 2013; Kung, 2016a).

On the organizational level, recruiting a Russian-speaking mental health professional to work at an FCC is a critical step in making culturally competent practice. The bilingual group leader was perceived by the mothers as being not only a professional authority, but also a cultural and linguistic mediator with Israeli society in general, as well as dealing with the mental health system in particular. These findings are in line with studies indicating that many first-generation FSU immigrants have difficulty speaking the new language even after many years in Israel (Kostareva et al., 2020; Remennick, 2012); however, even among those who acquired the new language, they preferred to express themselves in their mother tongue in cases of crisis and distress (Knaifel & Mirsky, 2015b).

Moreover, the mothers’ status as immigrants often led them to encounter linguistic-cultural barriers, as well as feelings of social alienation, which impeded their ability to receive resources that would be essential for the family's coping with mental illness. These findings support previous studies indicating that immigrant caregivers are in need of accessible services and cultural advocacy by professionals in order to fully utilize the rights and services to which they are entitled (Kung, 2016b). This is especially relevant in the case of FSU immigrants whose knowledge regarding the Western mental health field is extremely lacking (Dolberg et al., 2019). In the Russian-speaking groups, mothers were introduced to recovery-oriented community mental health services, which they had not been acquainted with in their country of origin. This learning process contributed to mothers’ perceptional change toward the mental health system and increased their sense of empowerment and hope.

The findings showed that FSU immigrant caregivers invested considerable effort in concealing the illness, which subsequently led to strong feelings of guilt, shame, and fear of rejection, which in turn led to their withdrawal from their immediate environment (Larson & Corrigan, 2008). In accordance with previous studies (e.g., Dolberg et al., 2019; Knaifel and Mirsky, 2015a), the present findings indicated that the experience of mental health stigma may be even more pronounced in high-educated families who consider themselves to be part of the Russian-Jewish intelligentsia. The process that the mothers underwent in the group helped to lessen their subjective sense of burden and normalized their feelings of guilt, shame, and anxiety.

A more comprehensive analysis of the findings indicated the grave implications of the fear of double social rejection on FSU caregivers. Because of the mental health stigma, mothers distanced themselves, either physically or emotionally, from their fellow Russian-speaking community members. At the same time, due to lingual barriers and cultural alienation, most of them reported not feeling a sense of belonging and openness toward the local-born Israeli population. Thus, they lose out in both ways and have difficulty finding a secure social and emotional space. In these circumstances, MFPGs for Russian speakers had essentially become the only place where the mothers felt protected from social rejection and developed a sense of belonging, which was based on cultural similarity and their common connection to the mental health field. Moreover, in line with Bourdieu's (1977) theory, participation in culturally adapted groups allotted FSU immigrants a type of social arena to preserve and foster their cultural capital. Within the group, they not only received social and emotional support, but they also were able to connect with their native culture by way of language, symbols, prestige, and common experiences. Therefore, not coincidentally, this socio-cultural space was maintained by mothers outside of the FCC, through telephone calls, gatherings in private homes, and joint celebration of Russian holidays.

These findings contradict previous studies that demonstrated FSU immigrants’ tendency to cope with crises and distress within the family space, and to be less likely to seek formal support (Shor, 2006; Slonim-Nevo et al., 1999). These differences can be explained by certain contextual factors. Firstly, most prior studies were based on testimonies gathered in the years following Israel's major wave of FSU immigration in the 1990s; however, after a prolonged period of acculturation in Israeli society, immigrants’ trust in formal support systems has increased. Secondly, the present study focused on mothers—a group of caregivers that are generally more involved with mental health services as compared with other family members (e.g., Levy-Frank et al., 2012). Thirdly, the mothers in this study were not only coping with SMIs in the family, but also with multiple social adversities related to their immigrant and marital status. In light of their minimal family structure (i.e., multiple single mothers, families with an only child) and having relatives who remained in their countries of origin (Remennick, 2012), mothers’ need for, and dependence on, external assistance is greater. Finally, the mental health stigma and fear of rejection prevented some mothers from receiving help from their nuclear or extended families, even when the relatives were in the country. The mothers’ participation in the group considerably broadened their support network and, to a large degree, substituted for the family support that they were lacking.

The findings may suggest that authoritarianism and parental control that have been previously noted as some of the defining characteristics of the Russian-Soviet family (Slonim-Nevo et al., 1999; Yakhnich, 2016) may be undermined in the context of coping with immigration and mental illness and lead to the blurring of family boundaries. On the one hand, in inter-family relations, mothers experienced a strong parental obligation to care for the adults with SMIs; but on the other hand, they experienced difficulty in caring, and often became over-involved in the lives of their adult children. It has been suggested that the collectivist cultural background of FSU immigrants, which emphasizes the centrality of the family on account of the individual's autonomy (Jurcik et al., 2013), may explain mothers’ difficulties in creating separateness within the family unit, even when it came at the cost of sacrificing and neglecting their personal health needs. Similar findings were reported in other studies that examined families from culturally collectivistic backgrounds, such as the Chinese populations in the US (Kung, 2016a). As part of the group intervention process, the mothers reexamined these patterns and recognized the importance of family separateness for promoting recovery conditions for themselves and their loved ones with SMIs.

Limitations and future studies

The present study has a few limitations. First, one-time self-reported findings must be treated with caution because they do not provide information about changes over time and may depict participants’ most pressing issues at the time of the interviews. Second, in this study I focused on participants’ experiences in Russian-speaking groups, but did not sufficiently assess the detailed cultural components of original family psychoeducation that are altered to suit their needs. Third, the current findings may have been impacted by selection bias, as not all immigrant caregivers who were approached agreed to participate. For example, the mothers who agreed to participate in the study were highly educated; this may have made them more likely to agree to partake in psychoeducation interventions and research in general. Fourth, the study represented mothers’ experiences only, but did not include other Russian-speaking caregivers such as fathers, spouses, and siblings.

In future studies, it will be important to recruit a more balanced representation of the FSU immigrant population in regard to family proximity, educational background, and socioeconomic status. In addition to examining family members’ experiences, future studies should be conducted with persons with SMIs and with mental health providers to get a multifaceted perspective on cultural competence in MFPGs. Specifically, further investigation of the components of original family psychoeducation programs and other evidence-based interventions that could be culturally adapted for FSU immigrants is needed.

Conclusion: Implications for clinical practice and policy

Theoretically, the present study supports the possibility of integrating evidence-based practices with cultural competence in mental health services. In the past, integration of these seemingly contradictory approaches involved epistemic and political tensions (Kirmayer, 2012a). The present findings demonstrated that this integration is possible, effective, and essential for addressing the lingual and cultural needs of FSU immigrant caregivers.

As for clinical implications, mental health professionals in Western countries who work at FCCs can use these findings to adapt family interventions to the needs of FSU immigrants. Due to the socialization practices of Russian-Soviet culture that discourage openness and expression of feelings (Jurcik et al., 2013), a psychoeducational approach that integrates directive, educative, and cognitive techniques may be more advantageous for FSU immigrants as compared to other approaches, such as dynamic techniques.

As for the educational aspect, the current study highlights the need for creating culturally adapted and translated materials that would help to promote effective illness management and enhance family support. It is important to distribute information in the Russian language in order to broaden participants’ knowledge of the recovery-oriented mental health approach, increase their awareness of community rehabilitation services for their family members with SMIs, and increase their motivation for utilizing these services. Because many middle-aged and older FSU immigrants suffer from language barriers, a lack of family support, and strong cultural stigma (Dolberg et al., 2019), in order to effectively utilize treatment and services, most of them require detailed explanations and cultural mediation by mental health professionals.

The very essence of the emotional work conducted with FSU immigrants is aimed to decrease their feelings of guilt and shame that result from the stigma of mental illness in the family. Therefore, it is important to both normalize and decrease these emotions during group sessions, as well as to refute the mistaken stigmatic attitudes existing toward families of persons with SMIs (Larson & Corrigan, 2008). An additional aspect that deserves a central focus in interventions with FSU immigrants is the dynamics of dependence-separateness relations within the family. Emotional and physical separation from adult children with SMIs can be cautiously encouraged; however, it is also important to be aware of the culturally rooted ambivalence that family members may feel regarding the separateness and autonomy of their loved ones.

From an organizational standpoint, it is essential to acknowledge the benefits that group meetings have on immigrant caregivers from the social and lingual-cultural angle. An additional value of MFPGs for Russian speakers is that they provide them with a secure social venue, not only for coping with mental illness but also for helping them with bureaucratic and social difficulties they encounter as immigrants in a new country. Self-help groups should be encouraged after the intervention ends, so that participants can keep in touch with each other and continue supporting one another over the long term.

On the policy level, it is important to incorporate cultural competence training for mental health professionals working with Russian-speaking immigrants in Israel and other Western countries, on system-wide, organizational, and clinical levels. The current pioneering study provided evidence regarding the implementation and effectiveness of culturally adapted psychoeducation groups in two Israeli family centers; however, it is essential to continue investigating the implementation of these interventions in diverse organizational and cultural contexts. These systematic inquiries are necessary in order to evaluate and establish cultural competence as a leading practice in mental health care for minimizing treatment gaps for immigrant families.

Biography

Evgeny Knaifel, PhD, is a social worker who works with immigrants from the former Soviet Union in Israel. He received his PhD at the Ben-Gurion University of Negev, Israel. Dr. Knaifel is also a research fellow at the Institute for Immigration and Social Integration – Ruppin Academic Center and training consultant at the Association for Excellence in Psychiatric Rehabilitation (AEPR). His research interests include the mental health aspects of immigration and acculturation, family caregivers, mental health literacy, and evaluation of culturally adapted interventions for individuals with mental illnesses and their families.