Introduction

Fore nearly 400 years Palestine has been occupied by Ottoman Empire, the British Mandate, and then Israeli military rule. However, over 18 month ago, the Gaza Strip become partially autonomous under the agreement between the PLO and Israel. Administration of Gaza's health services has transferred from Israeli to Palestinian administration. In the Gaza Strip 50% of the population is under 15, and other 40% between 16 and 40. The long period of occupation in addition the plight of Intifada have increased the number of stress related disorders. Palestinian children were in the forefront of the Intifada, often faced with direct violence or the threat of violence. Research has shown that 70% of Palestinian children in the Gaza Strip have been exposed to four to five traumatic experiences (GCMHP, 1992). One in five male Palestinians between the age of 15-55 has been arrested during the years of the Intifada. Thousands of females have also been arrested (Murray, 1990). A study on the psychological impact of imprisonment on 477 ex-political prisoners found that 41.9% have difficulty adapting to social life, 20.1% have sexual and martial problems and 29.14% need psychiatric intervention (GCMHP, 1993). Mental health services in Palestine are not able to meet the psychological needs of the population. Therefore, the need for community mental health services in Palestine is dire. Since its establishment in 1990 the Gaza Community Mental Health Program (GCMHP) which adopts a community approach mental health, has treated more than 8,000 people through its teams. Of these 32.18% from stress related disorders such as depression, PTSD, anxiety and hysteria; 24.72% from organic disorders such as epilepsy, mental retardation and organic brain syndrome; 7.34% from psychosis such as schizophrenia, schizoaffetive and depression; and 35.76% suffer from severe mental handicaps (Association for Handicap 1995). The bulk of people who need some form of mental health care is difficult to estimate but it is believed that 30-40,000 are incapacitated by various mental and psychological problems; the majority of them do not seek help, fearing the stigmatization associated with specialized psychiatric care. When these figures are augmented with the number of people affected by drug and substance abuse and by mental or psychological disorders associated with physical diseases or injury such as spinal cord injury, it becomes apparent that in terms of individual suffering, the burden on families and the cost to the community, the health services are faced with a problem of immense magnitude. It is crucial to mention that in Palestine the ratio of psychiatrists to the general population is around 1:350, 000 which makes the need for accessibility to mental health services more profound.

Community response

As in most Middle East countries, Palestinian culture has traditional ways of dealing with mentally disorder people; for example amulets which contain some verses of the Holy Quran are traditionally prescribed. (An amulet is a piece of parchment with religiously significant words and symbols, which is worn as a necklace. It is commonly believed that mental disorders are mainly attributed to work of some supernatural forces known as the "evil spirit" or evil eye" called "a-fa-reet." The traditional healer is the only person able to extract the "a -fa-reet" from the human body. Since mental disorders are highly stigmatizing, suffer seek the help of traditional healers or present their psychological complaints in the form of physical symptoms. Sadly, if a woman has a mental health problem, she and possibly her sisters will be considered unsuitable for marriage. These beliefs result in the denial of mental health problems. Such attitudes towards mental disorder are common not only in the general population but also among some managers, planners, policy makers and health workers. These attitudes are not always expressed openly, but they constitute a major obstacle to the development of rational mental health services. Clearly, traditional mental health care lone cannot hope to make a significant impact on a problem of such dimensions. It is increasingly evident that mental health care should no longer be provided in centralized institutions nor should its provision be concentrated in the hands of a few mental health care to address mental health problems has become increasingly accepted as an integral part of most mental health care systems. It is considered a major change in the source of care offered to mentally disordered people because it provides an alternative to institutional care. This approach moves away from the segregated and self-contained health care system within institutions to community-based therapy and patients' direct involvement in their health related issues. The mental health professional's role is to enable individuals to solve their problems. If basic mental health care is to be more accessible to a large population, it must be done through non-highly qualified and non-specialized community health workers at all levels from primary health care workers, nurses, doctors to those outside the health services such as teachers. The non- specialized workers can be supported by mental health professionals, but their work must be supported by mental health professionals, but their work must be to support the paint's or client's social network. Community mental workers could supplement the overburden of psychiatrists in meeting the population's health needs.

GCMHP as the first Palestinian model

In addressing this problem the director and the staff of GCMHP were convinced that the National Mental Health Services could not be considered in isolation from the wider problems of general health and of social and economic development. GCMHP offers mental health services at three community mental health centers primarily for traumatized children, women who have experienced domestic abuse, torture victims and drug addicts. Each center has its own multidisciplinary team which consists of nurses, a trained psychiatrist, psychologists and social workers. They conduct home visits, crises counseling, follow-up visits, family counseling and play therapy and provide services such as occupational therapy and E.EG. Each team collaborates with the existing health and non- health organizations Gaza. In addition to the implementation of community education campaigns, the Program has increasingly been call upon to train other Palestinian health care providers in various mental health skills. The training unit is responsible for in service training by inviting exports from all over the world to share their skills, experiences and knowledge. The Program also provides out service training by conducting seminars and workshops for existing NGOs, governmental sectors and primary health care clinics. In addition to public meetings which aim at reducing the stigma associated with mental illness and raising awareness of mental health problems in the community, a research unit was established to investigate and analyze of violence on the Palestinian population, considered the most important psychological phenomena effecting individuals and families. Simultaneously, the Program established a wide network of friends, supporters and professionals in Palestine majority of existing governmental and non-governmental organizations such as Primary Health Care Clinics (PHC), welfare organizations, schools, women's associations, religious institutions, etc. What makes the experience of GCMHP successful is that from its starts the Program has been based on multidisciplinary team work, is politically neutral, democratic, and serves as a model for the community in addition to incorporating training and research with philosophy of community mental health care. GCMHP introduced a few model which makes use of western experiences and knowledge and adopts it to our culture and needs. While being supported by the West, the survival of the Program depends on the commitment of the Palestinian trained professionals who put their training, skills and knowledge in the function of the Program and the community. The stuff of GCMHP are aware of the following challenges and difficulties: 1. The social stigma of mental health not only among lay-people but also among health professionals. GCMHP has attempted to address this problem through community campaigns and courses for para-professionals. 2. Lack of trained staff: GCMHP has approached this problem through continued education and staff development. 3. Lack of team spirit: our culture is highly individualistic, hierarchical and does not encourage nor has roots in teamwork. People blame others, are jealous and cannot work together. (One saying is: company is loss and play it solo). Several attempts to counter this individualism have been through team discussions, group therapy of the teams, and routine team discussion. We have also included awareness of multidisciplinary team with different philosophies and their management. This situation is more difficult and complicated for mental health professionals due to fact that culture stigmatizes mental health problems. Unfortunately medical professionals have contributed to this problem by ignoring the health aspects and community health in general. 4. Poor collaboration with the United Nations Relief and Work Agency (UNRWA). To strengthen the local network and referral system with UNRWA, GCMHP proposed sending some of their staff to spend two hours each in the primary health care clinics run by UNRWA directors of the Community Mental Health Programs and proposed to send twelve staff members to work at ten of the PHCs. Our project was approved after several meetings. However, when we arrive at the designated clinics, we found that the staff had not been informed. The failure of the proposed attempt to strengthen the referral system and train PHC staff in mental health issues stems partially from lack of communication between UNRWA directors and staff. However we plan to continue efforts to carry our original proposal. Contrary to our experience with UNRWA, we have been successful with several NGOs in Gaza and have managed to train staff members of NGOs in mental health issues and strengthen our referral system.

The philosophy of Community Mental Health (CMH) movement

The movement towards community based care is not new. Literature shows that during the past two decades there have been attempts to find appropriate ways to deal with mental health problems in a community which has tried to shift psychiatric therapy away from the traditional Freudian concentration on the individual and his unconscious motivation to social interpersonal oriented car (from intra-personal to interpersonal). In 1954 the term "therapeutic community" was formulated by Jones (1968) and is based on the principle that the patient as' social environment can be the instrument of their treatment under the supervision of medical/psychiatric professionals. Jones (1968) highlights that manifestation of mental disorders are reviewed in the context of the patient's relationships with other people. Intrapsychic determinants are recognized, but greater stress is laid on the interpersonal aspects of the person's functioning. CMH's main aim is to replace the long accepted of isolating mental patients in large institutions by offering them a socially stimulating environment, while avoiding exposing them to too many social pressures.

The community approach therapy is based on several foundations, among them: A) the micro-scopic view of the biomedical model: Medical intervention to treat mental "illness" is based on the germ theory of disease and advances in medical science. It creates the basis for what has been called the "medical model" or the "bio-engineering model" approach to tackling health problems, which dominates treatment of mental health mental health problems. The medical model of psychiatry emphasizes that mental disorders are illness caused by organic, biochemical or pathogenic factors. It could be argued that with the advance of medical technology, it is easy to forget that the patient's needs may sometimes be more effectively met merely by reassurance or a discussion and with some domestic or psychological problem in addition many patients burdened by psychological and social problems often present their complaints with physical symptoms. For health workers to treat only the physical symptoms is ineffective and a waste of resources and times as well as inappropriate to the patient's needs. The medical approach seems particularly inadequate when applied to psychiatric disorders where health and disease cannot be purely defined in the medical terms of the presence of pathogenic microorganisms. This leads to confusion and paradoxical situation where some "patients" have psychiatric symptoms but nothing is revealed laboratory examination (Engel 1977&1992). This has attracted considerable discussions among psychiatrists such as Engel (1972), Cochrane (1983) and Fried et al (1991) and others. They have addressed this by arguing that mental disorders described by doctors as "mental illnesses" are mainly diseases of the mind" not "diseases of the brain." "Diseases of the living" which can not be divorced from the individual's social context. "Diseases of the brain " refers to problems of neurology and brain pathology (Szasz 1985). In the former situation the "medical model" alone is inappropriate, its scope has to be widened to include the Psychosocial dimension of health. B) The anthropological contributions Ward (1989) highlighted that the anthropological view tends to conceptualize mental disorders in terms of social reaction to stress and environmental difficulties. This drew attention to the weaknesses of the medical model. C) The Primary Health Care (pHC) approach The PHC approach adopts the macroscopic view of health. It is based on the incorporation of medical, social, environmental and cultural factors which contribute to health problems. This approach calls for decentralizingmental health services and including in addition to health professionals, patients, traditional healers and others who can contribute in the treatment process (WHO1973, and 1990). D) Sociological perspective on mental health These view the term community mental health as all activities undertaken in the community (outside institutions) in the name of mental health. Thus one of its dimensions described by Bloom (1976) is called "community control." He means that health professionals are not the only source of data concerning the mental health related needs of a community nor they necessarily the best way to meet these needs. Rather, the staff of a community members or their representatives to identify the needs and plans for future health developments. The" community control" concept was described by Hopkin (1985) as minimizing the importance of professional's judgment and placing greater value on intuitive interpersonal skills than on professional training and experience in the care of patients. Freeman et al (1991) argues that the term "community control" suggests that community based mental health functions in harmony with the community it serves. This way the Paine's can achieve social adjustment and overcome the limitations caused by their illnesses such as the associated with mental illness. It could be argued that Rose's approach (1985) can be achieved through a rapport and close working relationship between the staff and patients to know about their health related issues and factors that might improve their health status. Health care workers have a responsibility to give people information enabling them to make responsible choices for themselves and thus facilitate patients' autonomy. In institutional care, however, the extent to which individuals can exercise their rights, share responsibility and their autonomy is very limited. Rose (1985) and Hawks (1975) argue that a strict hierarchical structure is prevalent in mental hospital and allow the stuff or patient to share in the decision- making.

The objectives of community mental health services are: - to make services more available and accessible to residents of a limited geographical area regardless of ability to pay; services should include 24-hour and seven-day emergency service. -to provide alternative care to those which exist in overcrowded and under-staffed institutions and work closely with inpatient units in the general hospital. -to reduce the number of hospital admissions through community intervention. -to provide a continuity of care in the community which is conductive to a better and more humanistic rehabilitation and leads to a more normal and satisfying life for the patient. -to adopt a preventive approach to mental health problems since many; problems are preventable by relatively unspecified community action or social change. -to overcome the widespread fear and stigma attached to mental health problems, through increasing community awareness of mental health issues. -to provide mental health services through multidisciplinary team in cooperation with primary heath care facilities and other none health institutions.

Institutional care

Supporters of community mental health care stress that the hospital is not natural social environment. Therefore hospital-based treatment cannot provide the full range of experience which enables patients to acquire confidence and self- esteem through success in their social roles. Goffman (1968) described hospitals as places where there is an excessive emphasis on physical treatment. Moreover, relationships between the patient and mental health professionals, mainly psychiatrists, are poor. The Royal College of Psychiatrists (1974) reported that in the average mental hospital a long-term patient is likely to see a doctor for only ten minutes or so every three months. Even a newly admitted patient is seen by a doctor for an average of only twenty minutes each week. Research carried out by MIND and Roehampton Institute (1990) found that 45% of 500 former inpatients interviewed had not found their psychiatrist easy to talk to, 66% were not satisfied with the explanation they had been given about their condition and 80% thought that they had been given insufficient information about their proposed treatment. In 38% of cases patients had never seen the psychiatrist alone but always during ward were often intimidating experiences.

Conclusion and recommendations

Despite the advances made in mental health care and treatment over the past years, there has been no clear "cure" for so called "mental illness." Indeed, the definition of "mental illness" is filled with complications. Consequently, mental health professionals have now focused their attention upon "mental health in an attempt to develop a more positive approach to mental health care. Illnesses, and more recently health, appear to have moved from the exclusive territory of medical practice to a more public domain. Undoubtedly, there is scope for "de-medicalization" of physical and mental health in the late twentieth century because some professionals realize that "problem of living" do not require pure medical treatment or remedy. These problems may respond to other kinds of care such as using educational methods to increase understanding and awareness and thus reinforce self-management. One way CMH care could be further implemented in the Gaza Strip is described in "A Proposal for the Implementation of a Government Community Mental Health Service in Gaza" (see Afana, 1992). This proposal, which aims to establish clinics in Khan Yunis, Rafah and Jabaliya, should be implemented in three phases. In the first phase, a committee made up of representatives from the health department; UNRWA, GCMHP and local voluntary health organizations will determine the objectives and the details of the program. In the second phase, a team of health workers will then be trained, most likely by professionals at GCMHP, and finally begin work at one of the clinics which will be opened before the others as a pilot program. With this proposal the clinics will serve an abridge between the hospital and the community since the hospital will offer inpatient care. However, there are a number of consideration regarding the CMH movement which should be examined: 1. The planning of a GMH must come though professionals who have contact with the community and not through a political program. The dangers associated with the latter are considerable as can be seen in the change in the US government's policy on mental health following the Kennedy administration (Mosher 1989& Ebben 1991). On one hand, efforts to present the need for change on a popular manner can lead to an inadequate recognition of some problems associated with mental disorders. On the other hand, if there is not enough effort made to maintain political interest supporting expensive ongoing programs of reform, especially after changes in government, there can be a loss of vital resources. 2. With the CMH movement there is a special need to protect the interest of the most severely distressed and /or chronically disabled psychiatric services users who are often the least equipped socially to exercise user power or practice self-advocacy. Effort to avoid stigmatizing and isolating such people must not undermine the requirements of clear resource allocation procedures and appropriate staff dedication. Otherwise there is likely to be a drift of focus towards less sever cases. 3. Under CMH care it is important to avoid conflicts between non-medical mental health professionals such as social workers and medical professionals as both are needed to work together. However, in the USA and European countries these conflicts are hampering the development of CMH. 4. CMH must have well-defined and limited aims. The American CMH movement has adopted almost all the local community problems. It is not possible to solve all the problems of an area with micro-solutions. Perennial problems such as bad housing racial inequalities, etc simply cannot be solved from a small local base, particularly a CMH program alone. It is important to decide what can reasonably be done, and done well. 5. Taking measures to prevent staff exhaustion is crucial; the working staff need to be supported and motivated. Training groups, staff supports groups, and multidisciplinary case discussions are not optional extras, they are basic needs to staff survival and function. 6. The current literature on CMH reveals that there are problems of professional boundaries and interdisciplinary conflicts. Many questions arise such as: will CMH take over the field of social welfare? Can we call or re-name mental health psychosocial welfare? In struggling with these issues, it may be convenient to evaluate and define the basic skills and training requirements for CMH. It could be argued when these questions are more clearly answered they will not dictate that all social work in a CMH should be done by social workers, that all clinical work be done by psychiatrists, or that community psychiatric nurses (CPN) should not be carry out tasks which are generally called social or psychological specialty work. At present, we see some encouraging evidences of such trends. In the U.K, the CPNs have been found to work successfully in social work and successfully in social services work and psychotherapy clinical work (Linson & Brown 1991). 7. We must avoid overestimating public tolerance of the mentally ill. Evaluation of public tolerance and attitudes towards mental health has to be considered in the planning process for any successful CMH. 8. Users' satisfaction with the services offered must be evaluated to determine whether the services offered meet the community's needs.