Disaster and Mental Health:
The Palestinian experience
By:
Eyad El Sarraj, M.D.¨
Samir Qouta, PhD¨
Background:
The
The modern Palestinian tragedy goes back to the late part of
the 19th centaury when the Zionist movement was created in the wake
of nationalism which spread in
In
the course of their modern history, the Palestinians have found themselves
becoming the Jews of the
In
the first few years of their catastrophe they were bewildered, unable to
comprehend why they had to pay the price for the European persecution of the
Jews and why they were not allowed to return home. Now, many years later, their
homes are occupied by Russian and Polish Jews. More baffling to the
Palestinians were the many occasions when the Security Council of the United
Nations passed resolution after resolution demanding their repatriation, to be
met with
In
twenty years after their uprooting many Palestinians became University
graduates and were in every university. They had some pride. Some of the
educated people formed the resistance movement. They believed that the Arab
countries would never fight
In 1993 the
Palestinian
radical groups in their despair and in defiance used suicide bombing against
civilians in
In
June 2002,
The
state of mental health in
One old Palestinian refugee woman described her dramatic
experiences in this way:
When I returned to my
home one evening, I found it destroyed. The furniture was scattered and broken.
I began to weep. At that moment I began to remember the time when we were
uprooted from our country,
Saida
60-years women,
This
disaster of uprooting left strong influence on the Palestinian community and it
is known from the literature that traumatic events are harmful for the
development of the individual. It has been suggested frequently that severe
disturbances of the ‘normal’ development during childhood will result in
psychopathology in adulthood or at least that the quality of life in adulthood
is treated (Freud and Burlingham 1943; Dunsdon 1941; Brander 1941; Fraser
1974).
For
this reason it is important, when exploring the impact of specific types of
human rights abuses on victims and on the Palestinian society, always to take
into consideration the global context in which they are occurring and to which
they are adding yet another element of suffering. It follows, naturally, that
any intervention designed to improve mental health, and to prevent further
human rights abuses, must acknowledge and incorporate the significance of the
intertwined elements of past and present experience, as well as attitudes
towards the future. Even the impact of the Peace Process on Palestinians cannot
be comprehended without understanding the initial meaning of the Oslo Agreement
itself and what it represented. In turn, this cannot be understood without a
clear picture of what the first Intifada (1987-1994) as well as Al-Aqsa
Intifada (2000), meant to this society, which itself cannot be understood
without a clear conception of life under occupation.
In
the literature the recovery of trauma has always been described from a
protective and supportive perspective. In the
The
mean age of the population of
Fourthly,
in the first Intifada, children and adolescents were actors, and it is
especially this fact which makes the situation of the
In
facing and confronting the repeated and on going various forms of trauma and
violence, Palestinians were to resort to the basic security structures which
have helped them historically to survive. The family cohesion, tribal
structure, and a high degree of political involvement have helped the
population adaptive mechanisms and its ability for resilience. In recent years
the rise of Islam as a political movement of resistance has further sharpened
their resolve although it has politically radicalized increasing segments of the
population.
It is a tragic fact that children have become laboratories
for the study of the relationship between trauma and violence, conflict, and
children’s well being during war. Wars and battles have been fought without
interruption in the region for fifty years. None of these wars, however, have
brought a solution to the conflict between Jews and Arabs.
Since the war area is small it is difficult to protect
children from sights of destruction or protect them from the dangers of war and
insecurity. Many of these children have taken part in their national struggle.
Even if they were not actively fighting on the streets, as so may were, they
still could not help but experience the national struggle on an emotional
level. The atmosphere of insecurity, danger, violence, and hostility that
prevailed during the two Intifada inevitably left scars on the mental health of
the Palestinians children.
In
(Fig. 1) the concept of 'trauma' may be defined differently than it is in
literature dealing with other contexts. Trauma in the Gaza situation is
on-going and is both direct and indirect. Direct trauma refers to the more
traditional definition of the concept, and in the Gaza situation, it refers to
the moments of organized violence during the first and present Intifada. In
principle, but not necessarily, direct trauma refers to an experience in the
past. Indirect trauma refers to the long-term consequences of the direct trauma
and to the specific context that is defined by the direct trauma. The
consequences of indirect trauma other than direct trauma are difficult to
specify in terms of causality. It may well be that indirect trauma is more
important as a mediator than as a cause of pathological stress
reactions. In principle, indirect trauma refers to both the past and actual
circumstances.
Due
to the difficulties in conducting nation wide research and service projects in
the West bank and Gaza Strip, we in the Gaza Community Mental Health Programme
have focused on the population of Gaza. The results of our work however could
also be applied to the Palestinians living in the West Bank since both
populations live under similar conditions and share the same cultural and socio
economic life.
Figure 1
History of Uprooting
Life under Israeli occupation
Since
the Israeli occupation of the West Bank and Gaza Strip in June 1967, life for
the Palestinians has been characterized by multiple social problems.
Israeli
policies in the occupied territories are condemned worldwide as well as inside
Israel mainly because they ignore the basic human rights of Palestinians, and
because Israel continues to build Jewish Settlements in the West Bank and in
Gaza. The record of human rights abuse by the Israeli occupation authorities
was monitored by Palestinian, Israeli and international organizations including
Human Rights Watch, Amnesty International, Israeli Physicians for Human Rights
(PHR-Israel) Israeli Campaign against torture, Palestinian center for human
rights, and the independent commission for citizens rights.
From
the early days of the Occupation, Israeli intentions were made clear; to keep
the land and to exploit the Palestinian work force. By military orders the
Israelis curbed all forms of freedom to ensure a tight grip on the Palestinians.
All expressions of Palestinian identity, even singing for Palestine, waving a
flag or forming political parties were considered anti-state offences.
Traveling, meeting or forming professional syndicates were only allowed by
military orders. Thousands of Palestinians were not permitted to be united with
their families, while land was continuously confiscated to build settlements
for Israeli Jews. Humiliation,
harassment and discrimination were the official undeclared policies.
In
the first five years of the Occupation the Palestinians put up a stiff
resistance and took to armed struggle, but at a heavy price. Throughout the
Occupation approximately 400,000 people have been detained and the majority of
them tortured.
Over
the years the Israeli policies have created a culture of fear and paranoia with
a violent projection of aggression, while keeping an inner image of Jews as
victims. Their paranoia was continuously nourished by the surrounding Arab
demagogic leaders who vowed impotently to throw the Jews into the sea.
The
Palestinians on the other hand are physically dispersed in exile and are
emotionally traumatized. Their feeling of victimization is deep. Their
experience of trauma is overwhelming and their inner psyche has been badly
injured. Their mood therefore is greatly sensitive, quickly swayed to extremes
and their reactions rapidly swing between euphoria and despair. They will never
forget their suffering and will perhaps never forgive.
During
the years of Israeli occupation, besides the denial basic human rights, harsh
economic measures were taken and social and political rights were restricted.
Since 1967, more than 40% of the land of Gaza has been confiscated by the
Israeli occupation authorities. This land has been turned over only for the use
of Jewish Israelis. Thousands landless Palestinians have been absorbed into the
Israeli economy as cheap, unskilled or semiskilled laborers. Palestinian
farmers who have managed to keep their land have been subjected to military
restriction that control water use (Lowi, M., 1982). As a result of these and
other measures, the Palestinian economy has been crippled by the Israeli
occupation, and the occupied territories have become one of the Israeli's
largest export markets 9for a comprehensive analysis the reader is referred to
Sara Roy book “redevelopment”
Palestinians
were denied freedom of speech, meeting, traveling, and publishing, and were
punished for expressing their national identity in any form. Even a wearing a
dress of the colors of the flag or singing a national song were consider a
crime against the state (Marsella, A. etc.1994).
The
Israeli policies in the occupied territories were seen as designed to force the
majority of the Palestinian out, and to resettle the remainder in small
enclaves surrounded by Israeli settlements.
The
first Intifada
In
December 9, 1987, the Palestinian popular uprising, the Intifada, against the
Israeli military occupation opened a dramatic new chapter in the
Palestinian-Israeli conflict with far-reaching psychological, political, and
socio-economic consequences. From the beginning, children were active in the
core events of the Intifada and came to be known as "the children of the
stones." Many posters, postcards, articles and books portray images of the
children of the Intifada throwing stones.
The
Israeli army's response to the Intifada was to increase brutal and oppressive
measures. These measures included killings, detentions without trial,
demolition of homes, torture, deportation, and curfews. The Palestinian Human
Rights Information Centre estimates that during the period of the first
Intifada from December 9, 1987, to December 31, 1993, Palestinians suffered
130,472 injuries and 1,282 deaths, of which 332 were deaths of children. Among
victims were those who were shot, beaten, tear gassed, or burned to the extent
that they are suffering from permanent disability. Approximately 57,000
Palestinians were arrested, many of whom were subjected to systematic physical
and psychological torture. Records show that over 481 were deported, and 2,532
had their homes demolished. The psychosocial and financial costs for the
affected families in terms of medical and psychosocial care, loss of productive
time, chronic disability, loss of function, and loss of life and property are
enormous (Khamis, V., 1995a).
Most children
living in the Occupied Palestinian Territory (OPT) have directly experienced
physical or psychological violence or they may have witnessed violence directed
towards their families and friends. These experiences occurred in the specific
historical context of Palestine, and were resonant with the uprooting of their
families from their country in 1948.
Bombing
happens suddenly, without prior notice. It is this unpredictability that is
considered to be the most traumatic factor for human beings. The method used by
the Israeli army in shelling and demolition are psychologically devastating as
the army carry out such attacks suddenly and in the middle of night or
sometimes in midday, when people are engaged in their daily life.
Curfew
Curfews
are considered as a collective punishment, turning every home into a prison.
Under the curfews all aspects of daily life are paralyzed, the result is the
total break down of normal pattern of social and the economic interactions.
One
observation that helps interpret the results is that curfews create
frustration, which means unpleasant emotional state resulting from a blocked
goal, rather than the event itself (Atkinson, 1985). One of the main common
responses to frustration is active aggression, and if the stressful condition
continues, and the child is unable to cope with it, apathy may deepen into
depression (Qouta, El Sarraj, 1994).
During
the five years of the Intifada, the population in Gaza Strip was confined to
their homes during curfews every night from 7 p.m. to 4 a.m... Many times
curfews were imposed around the clock for various periods. During the Gulf war
curfew was imposed for a continuous 42 days with people confined to their homes
except for three hours every week.
In
the study of Collective Punishments and Mental Health we tried to assess the
effects of curfews on the children behavior. It was found that the curfew leads
to negative psychological effects among the children, Results show that 66.1%
children began to fight each other, 54% were afraid of new things, 38% started
to develop aggressive behavior, 18.9% started to suffer from bed-wetting and
2.3% had speech difficulties.
Torture
Throughout
the years of occupation the use of torture in Israeli interrogation centers was
sanctioned by law until the high court of Justice ruled in 1999 that all forms
of violence during in interrogate are unlawful.
In
the first 20 years of occupation however over 400.000 Palestinians were jailed
for various periods, the majority of them tortured. Methods used in torture
ranged from psychological to physical and the impact on the society and
individuals far reaching·.
Parenting
Style
Mental
health professionals show increasing concern about developmental risks for
children who fall victims to political violence and war. Family and
parent-child attachment are considered important in providing a protective
shield for children's psychological well-being in dangerous conditions (Freud
& Burlingham, 1943; Garbarino, Kostelny & Dubrow, 1991).
Researchers
assume that experiences related to political violence and war constitute a serious risk for the
well-functioning family (Garbarino, Kostelny, 1993; Hobfol et. Al., 1991). War
and political conflict therefore disrupt some of the basic parental functions,
such as protecting children and enhancing trust in security and human virtues.
The gender of the child seems to be an important
determinant of both parenting and the association between traumatic events and
the quality of perceived parenting. Research confirms that parenting styles
vary according to the gender of the parent as well as the gender of the child.
Mother-child interactions are characterized by relatively more warmth and
responsiveness than father-child interactions, whereas the latter are likely to
be marked by the father’s relatively greater punitive, firm, and restrictive
behavior towards his children.
Palestinian families in the Gaza Strip are large,
and people show strong affiliation to them. “El Hamula” (the extended family)
continues to play an important protective role in modern life too.
Traditionally, children submit to the authority of their parents, and older
members of the family enjoy special status. The constant enemy threat and the
collective trauma of losing their homeland in 1948 have increased social cohesion in Palestinian
society.
However, the first Intifada created a situation
that apparently shook traditional parent-child relations and family hierarchy.
First, the increased influence of political parties decreased the social role
of the extended family. Second, children and youths played a very active role
in the national struggle. They were an
essential element in the initiation, planning, and organizing of demonstrations
against and confrontations with Israeli soldiers (Kuttab, 1988).
Palestinians
have expressed serious concern about the future consequences of these shattered
parental bonds. There is common belief that children who threw stones and
fought against the occupation army also challenge their parents'
authority.
Children
living in conditions of political violence and war have been described as
"growing up too soon", "losing their childhood", and taking
political responsibilities ample maturation (Boothby, Upton, & Sultan,
1992). This development is predicting to result in negative psychological
consequences (Garbarino, Kostelny, & Dubrow, 1991).
The
associations between traumatic events, children's gender and political
activity, and parenting styles showed that the more the children were exposed
to traumatic events, the more they perceived both their parents as strictly
disciplining, rejecting, and hostile, and their mothers as more negatively
evaluating. Traumatic events increased perceived parental rejection and
hostility only among boys, and perceived strict discipline only among the
girls. Although politically active children perceived both of their parents as
more negative in general. In the families exposed to a high level of traumatic
events, passive boys perceived their fathers as more rejecting and hostile than
active boys did. It is suggested that mothers and fathers rear girls
restrictively and with greater attention, and boys with rejection, when the
family faces traumatic events. In exposed families, fathers also tend to
discourage boys' political passivity and apparently encourage activity.
Children who enjoyed good parenting have the ability to adapt and achieve good
mental health than children whom had poor parenting (Punamaki, Qouta, El
Sarraj, 1997).
Research focusing on the associations between traumatic
events, children's gender and political activity, and parenting styles showed
that the more the children were exposed to traumatic events, the more they
perceived both their parents as strictly disciplining, rejecting, and hostile,
and their mothers as more negatively evaluating (Tables 2 and 3). Traumatic
events increased perceived parental rejection and hostility only among boys,
and perceived strict discipline only among girls. In the families exposed to a
high level of traumatic events, passive boys perceived their fathers as more
rejecting and hostile than active boys did. It is suggested that mothers and
fathers rear girls restrictively and with greater attention, and boys with
rejection, when the family faces traumatic events. In exposed families, fathers
also tend to discourage boys' political passivity and apparently encourage
activity. Children who enjoyed good parenting have the ability to adapt and
achieve better mental health than children who had poor parenting.
Table
1. Mothers: relation between traumatic
events, child’s gender and political activity, and perceived parenting styles
(n=56)
|
Independent Variables |
Strict Discipline |
Intimacy
and Love |
Lax
Control |
Negative Evaluation |
Rejection
and Hostility |
|||||
|
Beta |
r |
Beta |
r |
Beta |
r |
Beta |
r |
Beta |
r |
|
|
Traumatic
Events |
.14 |
.22 |
.03 |
.00 |
.07 |
0.4 |
.23 |
.32 |
.10 |
.23 |
|
Gender |
.28 |
.32 |
.01 |
.02 |
.10 |
0.8 |
.34 |
.40 |
.32 |
.37 |
|
Political
Activity |
.01 |
.11 |
.00 |
.01 |
-1.8 |
-1.2 |
-.04 |
.14 |
0.9 |
.21 |
|
R2 |
.12 |
|
.00 |
|
0.3 1.20 |
|
.21 |
|
|
.16 |
|
F
(6,56) |
4.71 |
|
.01 |
|
ns. |
|
9.06 |
|
|
6.72 |
|
P |
<0.04 |
|
ns. |
|
|
|
<0.0001 |
|
|
<0.003 |
Table 2. Fathers: relation between traumatic events, child’s
gender and political activity, and perceived parenting styles (n=56)
|
Independent Variables |
Strict Discipline |
Intimacy
and Love |
Lax
Control |
Negative Evaluation |
Rejection
and Hostility |
|||||
|
Beta |
r |
Beta |
r |
Beta |
r |
Beta |
r |
Beta |
r |
|
|
Traumatic
Events |
.17 |
.28 |
.02 |
-.04 |
.15 |
0.1 |
.07 |
.06 |
.25 |
.31 |
|
Gender |
.37 |
.42 |
.09 |
.05 |
.15 |
0.14 |
.11 |
.08 |
.40 |
.44 |
|
Political Activity< | ||||||||||