Mental health and mental health services in Palestine (2014)

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Mental Health in Palestine

William R. Woodward, University of New Hampshire

Presented the European Society for the History of the Human Sciences, July 22-25, 2014, in

Oulu, Finland

Obligation of an Occupier shirked

Since 1967, Palestine is a land under occupation by a foreign power. Israel has not

fulfilled the obligations of an occupying power in that Israel’s own Mental Health Act has not

been applied to Palestine. A legislative framework for mental health has been lacking, with

consequences for unemployment, refugee status, and traumatic effects of occupation and war

(Murad & Gordon, 2002). After the Second Intifada or revolutionary uprising in 1990, Israel

began construction of the wall that impeded thousands from getting to work or to medical

services in Israel or the occupied territories. In 1994, at a meeting of the Pan Arab Federation of

Psychiatrists, members began to draft a proposed Mental Health Act as a framework to be used

in each Arab country (Chaleby, Pakhawi, Azim, 1996).

By the early 2000’s, the separation wall precipitated a humanitarian crisis such that the

International Committee of the Red Cross withdrew its short-term emergency aid program,

arguing that to continue would be relieve the Occupier of its financial responsibility under

international law. ICRC shifted focus to documenting damage to civilian infrastructure and

policies restricting freedom of movement (Schorno, 2004). The U.N. Office of the Coordination

of Humanitarian Affairs took over, though they too do not provide relief (Shearer, 2004). It

remained to voluntary agencies to support the population, working with the Palestinian Ministry

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of Health and the United Nations (Le More, 2004). Astoundingly, Palestine is the envy of some

Arab neighbors for its integration of local, regional, and international funding and services.

Thus, in 2002, the World Health Organization began a Palestine Mental Health Project, in

cooperation with the Palestinian Ministry of Health. In addition, they had partners with mental

health professionals from the West Bank and Gaza, and from French, Italian, and U.K. sources.

The project had a five year implementation plan, involving hospitals in Bethlehem and Gaza, and

the founding of community mental health services (in Bethlehem, Ramallah, and Hebron). The

Project had a public face through anti-stigma initiatives, service user groups, and family

associations. Trauma-focussed care was integrated into these systems, thus avoiding the common

problem in conflict or post-conflict situations of organizing care by catchment areas rather than

by disease categories (WHO, 2006). In 2008, the European Union pledged another $3.5 million

Euro to the Project (IRIN, 2008). The goal was to get family groups to support the relatives of

people suffering emotional problems and mental illness.

Mental Health Facilities and Research Initiatives

The mental health facilities themselves are of course paltry (Afana et al, 2004).

Apparently, Bethlehem has the only psychiatric hospital on the West Bank; before 1967, it

covered both West and East Banks of the Jordan. Bethlehem Hospital has 320 beds, of which a

third are occupied by epileptics. It spawned community psychiatric clinics in Ramallah, Nablus,

and Jenin (Gordon et al, 1996).

The Gaza Hospital, established in 1979 and restored in 1994, has a mere psychiatric 40

beds. General hospitals in Gaza City include Al-Ahli Arab Hospital, Al-Shifa Hospital with 600

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beds, and Al-Wafa Rehabilitation Hospital. The solution in Gaza is community mental health

centers.

The Gaza Community Mental Health Project (GCMHP) provides community mental

health services, trains in community mental health and human rights, and sponsors field research

(Thabet & Vostanis, 1998, 1999). The Shamas Center deals with rehabilitation of brain-

damaged and severely handicapped children. Doctors without Borders provides for rehabilitation

of former political prisoners. Hebron offers support for mentally-handicapped. Gaza has the Al-

Wafa Hospital, which was bombed last week and now needs $3 million in repairs (Goodman &

Alashi, 2014, July 18). The Union of International Churches is involved (Alana et al, 2004). Al-

Wafa Hospital in Gaza City does rehabilitation.

In a land with roughly 40% of the population depressed, Palestine sadly offers a rich site

for depression research. NIH funded it recently in the modest amount of $300,000. One research

topic is what factors have allowed the other 60% to avoid depression (Upbin, 2013). A wider aim

is to counter Palestine’s brain drain and to offer opportunities for research. The Palestine

Neuroscience Initiative opened in 2009 in Al-Quds and has 22 students, 14 medical specialists,

and 4 therapists. It has partnerships with Rutgers, Harvard, Lausanne, and Trieste.

Keeping the Focus: Interdisciplinary, International, Human Rights

Recently, a multilevel approach to mental health care was called for (Jabr et al, 2013). (1)

Care requires interdisciplinary teams, in which the psychiatrist works with social workers and

psychologists. The patient and his or her family should be thought of as team members. (2)

Primary care physicians must be trained to screen and treat mental health problems. This training

dramatically increases referrals. Diagnosis and treatment should include general medical

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disorders “at the point of delivery.” (3) International partnerships in human sector resources and

research are ongoing, e.g., Cognitive Behavior Therapy with British and Palestinian clinicians

(Palestinian Neuroscience Initiative, website). Finally, (4) public health and human rights must

go together by preventing human rights abuses, especially against women and children, through

legislation and efforts to reduce risk factors like family violence, community violence, and

military violence.

Outrage at unjustified massacres of Palestinians is peaking again in summer 2014 as

Israel launches operation “Protective Edge.” Miko Peled, author of The General’s Son, remarked

recently that murder is nothing new; it has been ongoing for six decades since 1948. He pointed

out that we should not confuse Palestinian resistance to brutal oppression with Israeli apartheid.

Yet some mental health practitioners urge the Palestinian people not to focus on politics. The

Olympia-based ITTP claims “Intifada means uprising against injustice. It has a positive meaning

for us. We help them to understand that they ARE traumatized.” ITTP sends practitioners into

the schools to use the arts, creative writing, dance, to bring people together and overcome

isolation of trauma victims (ITTP, 2013).

The Gaza Community Mental Health Project

Psychologists for Social Responsibility, a division of the American Psychological

Association, supports the Gaza Community Mental Health Project (GSMHP). They treat “the

consequences of living in a war zone” (PsySR). They point out that restrictions from family

support, worries about family and community, contribute to depression and ongoing cycles of

violence. Children are coping with multiple losses, poverty, harsh restrictions. Their charitable

foundation is located in Boston. They receive funding from a consortium of Swedish,

Norwegian, and Danish sources. They receive support from Psychoanalysts for Social

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Responsibility, Physicians for Human Rights-Israel, Mental Health Professionals for Human

Rights, the Psychoactive Group, and the Coalition for an Ethical Psychology.

Let us look more closely at one study from the Gaza project. Dr. John van Eerwyk

founded the Gaza trauma treatment program with training missions in 1991 and 1993. He

expanded it into The International Trauma Treatment Program in Olympia, Washington in 1998

(ITTP, van Eerwyk, 2013), which has trained over 20 practitioners in a dozen countries, bringing

two per year to Olympia to collaborate in refining culturally-based ways to treat trauma. In 2003,

two Palestinians were invited for 3 month stays in Olympia, Israel denied their visas, Physicians

for Human Rights sued, and the visas were eventually granted. Two Israelis had planned to

come, but the delays interfered with work and they could not participate.

Two researchers examined social disadvantage related to anxiety disorders (Thabet &

Vostanis, 1998). They gave the Revised Children’s Manifest Anxiety Scale to 237 children in

112 schools. To identify troubled children, they also administered the Rutter Teacher Scale to

teachers. The findings did not support the common view that children express mental health

symptoms through somaticizing symptoms. They found PTSD symptoms in 73% of the children,

age 6-11. Overcrowding and large family size were not associated with anxiety in rural families,

whereas socioeconomic conditions were associated with anxiety were in a study of 1000 poor

families in Newcastle, U.K. and in Palestinian refugee camps. Their findings show similar rates

of anxiety across all cultures including the U.S., about 21%, and the symptoms increase with age,

especially with girls. As abstract thinking grows, so does self evaluation, including worries and

nightmares.

The same two researchers visited two camps and compared the community treatments

(Thabet & Vostanis, 1999). They attended team meetings, did out-patient consultation, and

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discussed case management. Behavioral symptoms included enuresis, nightmares, emotional and

oppositional disorders, learning disability and child protection issues. They compared the Khan

Younis camp in the South with the Jabalyia camp in the North of Gaza. They reported “high

clinical standards” under “extremely adverse circumstances (301).

Nuseirat Refugee Camp has one of eight community mental health centers in Gaza

(Shurman, 2012). Called “New Horizons,” this health center forms healing communities through

art, song, and dance therapy. It has an affiliation with the Bay Area Children’s Alliance in

Oakland, CA. Ayman Nijim, age 29, went to Baghdad to work with youth in 2003, just before

the U.S. invasion to study French and journalism but shifted to an interest in social work with

youth. He realized that his sense of “powerlessness” was common to many young people in

Palestine. He conducts daily workshops and sees symptoms of anxiety, hyperactivity, attention-

deficit disorder, and extreme introversion.

Issues in Identifying and Treating Mental Illness

A Norwegian study of general practitioners in the Gaza Strip showed that GPs recognize

serious mental illness in only about 12% of cases, while 88% of mental illness remained

undetected (Afana et al, 2002) whereas other countries have detection rates as high as 50%.

However, sex of patient and GP, age of patient and GP, and postgraduate training were also

factors, as well as country. For example, women GPs over 40 have higher detection rates.

Overall, a U.S. study showed only 20% recognition of psychiatric disorders, while a Norwegian

study showed 46%. However, attitude toward mental health problems may also be a cultural

difference. The social stigma of mental health problems is high in the Middle East and Africa, so

patients may be reluctant to reveal symptoms.

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One authority on cross-cultural counseling with Arab-Palestinians is Marwan Dwairy

(1998, 2006), an Israeli clinician and academic. He describes a “collective personality” among

Arabs and Muslims, whereby diagnosis, assessment, and therapy need to reflect cultural values

on family. For example, a counselor who uses his or her authority to counsel clients, especially

female ones, to freedom and equality is in fact confronting a cultural value (2006, p. 108).

Typically a family figure (not the patient) decides whether to continue therapy. A misstep can

often cause a patient to leave. This may come from not being understood, or from feeling their

culture challenged.

Deconstructing Cultural Stereotypes in Psychiatry

We must be careful about embracing national or cultural stereotypes. Such was the article

by Harold Glidden in 1972, “The Arab World,” which appeared in the American Journal of

Psychiatry. Glidden identified “two key emotions,” shame brought about by their defeat, “which

can only be eliminated by revenge.” Arabs also allegedly fear domination by other Arab groups.

Edward Said (1979) lashed out at Glidden (1972) in his classic, Orientalism, noting that Glidden

only cited four references – a book on Tripoli, an Egyptian newspaper, an Italian periodical, and

a book by an Orientalist. Glidden characterized Arabs as skilled in subterfuge and low in valuing

peace, as well as being culture based on shame that attains prestige through dominating others.

Such stereotypes hardly belong in a leading psychiatric journal. Or does it reveal something

about racial bias in U.S. medicine? Negative stereotypes of the rich sheik, the camel, or the belly

dancer pervade the U.S. media (Iverson, 2005). Do they also infect the scholarly journals, where

“terrorism” is a focus of psychological research, while “apartheid,” and “resistance” and “state

terror” are conspicuously absent.

Excellent Trauma Study identifies Loss as Factor in PTSD

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An example of a mental health treatment for trauma outside the mental health system is

the Treatment and Rehabilitation Center (TRC) for Victims of Torture in Ramallah, West Bank.

(http://cvt.hutman.net/). A psychiatrist who specialized in treating political prisoners since 1987

founded it under the auspices of the Mandela Institute for Political Prisoners in 1994. TRC offers

psychosocial therapy in homes, individual and group therapy, summer camp activity, public

meeting with need assessment questionnaires.

A model mental health study involved collaboration between the University of the Negev

in Israel, the University of Calgary, and the TRC at Ramallah, Palestine. The topic was “Mental

Health and Violence/Trauma in Palestine: Implications for Helping Professional Practice” (Al-

Krenawi et al, 2004). With an extensive review of the literature since the 1980s, the authors

followed four cases taken from the clinical records at the Ramallah Center since 2000. In Case 1,

Amjad is an 18-year-old who has supported his family of seven in a 2-room home in a refugee

camp by selling vegetables after his father was incapacitated by a bullet to the brain. In Case 3,

the Ashraf family was headed by Walid, a 39-year-old high school graduate and curtain designer.

They were self-sufficient until a bomb destroyed their home and left the mother with a back

injury. They could not afford to live in another house, so they returned to the damaged one. This

produced recurring fear that their house would be bombed again. The children feared going

outside. All four cases involve a loss. Even the paralysis of the father in Case 1 also

destabilized a home. The destruction of home is a destruction of history and a sense of

belonging. It is “the destruction of familial dreams” (193). As well, loss of home or continued

living in a damaged home is a retraumatization of the exile that Palestinians have experienced

since the catastrophe of the violent creation of Israel in 1948. This feeds into the

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symptomatology of PTSD: sleep disturbances, loss of control due to unpredictable timing of the

shock, hyperarousal and anxiety, and repetitive intrusive thoughts.

PTSD among Palestinian Children

Vivian Khamis of the United Arab Emirates studied 1000 West Bank and East Jerusalem

children, of whom 86% were Muslims, 14% were Christians (2005). She used a stratified

random sample using age, gender, supervising authority (government, private, U.N.), and grade

level. A structured clinical interview identified PTSD, focusing on the module for post-

traumatic stress disorder. Symptoms of PTSD included re-experiencing the traumatic event,

avoidance of stimuli associated with it, numbing, and increased arousal. She found 55% of

Palestinian school age children suffered PTSD at the hands of the Israeli army, including injury,

loss of a family member, imprisonment with beating, and home demolition. Economic hardship

was associated with PTSD, as were harsh discipline in the family, and living in a refugee camp.

She concludes that children should be screened for PTSD and services offered, including

psychosocial interventions in the family system.

Nadera Shalhoub-Kevorkian (2009) is a Palestinian feminist researcher employed at

Hebrew University. She gathered six focus groups involving 91 children in the Gaza Strip. She

believes that the best way to study war trauma is through the accounts of the children. An 11

year old girl remarked:

How can the world live in peace when we suffer every single minute? I am sure they pay

a high price. See, every time they hear about our resistance, they feel weak, I believe that

I , Hidaya, [a] very simple [girl], am much stronger than all of them, otherwise why

would they send a tank, big computerized planes and machines to kill me. They fear the

Palestinian child, and therefore we must stay strong, love each other, help and support the

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needy, and be educated. They fear educated people that can speak English and tell the

world about their crimes (p. 337).

When asked about a most painful incident, many mentioned loss of homes. This became a

double loss as they became homeless in their own neighborhood, and thus more vulnerable. A

14 year old named Sliman said:

I dream a lot about Jews – that they attack us and want to break us down and want to take

us away from our land. I want them to go away to occupy another land. Our land has

been occupied since 1948 through 2006; it is a sin that they do to us (p. 338).

When children are encouraged to speak up, they “share their ordeals” and create “new modes of

coping.” Their stories reveal “structured inequalities.” Children are stuck in a “here and now,”

theorized Martin-Baro; their historical memory is silence by fear. The cure is to encourage “acts

of questioning,” “writing poetry, or supporting others” (Baro, 1996).

Do the Obligations of Israeli Citizenship include Occupied Territories?

I am encouraged by Dovon Navot, a young Israeli political scientist, who sees three

groups in Israeli society: those who are withdrawing like Ben-Gurion or leaving the country,

those pushing forward with neoliberalism of the so-called “free market” such as Netanyahu, and

those who want a new social contract with all the citizens of Israel (2013). This new contract

would be based on obligations of citizenship, not just on rights, and on social justice. The

younger generation wants to reach out to all groups in Israel. Navot acknowledges that the

relationship with Arab citizens has been one of “coercion, manipulation, bargaining” (p. 42).

Sadly, he does not even mention the brutal treatment of neighbors in Palestine. Other scholars

have argued that Israel has lost the progressive Enlightenment ideals of world Jewry (Clark,

2014). Young Palestinians are contributing to the healing process, like Ayman Najim, who

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manages classes for traumatized children in Gaza City, and is now studying “Transformation

across Cultures” at the School for International Training in Vermont.

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