Training in Community Mental Health and Human Rights Activities 2002

The general political and economical situation deteriorated further during the first half of this year. Internal closures within the Gaza strip imposed by the Israeli army affected the work of GCMHP as a whole during the first six months of this year, because it prevented our staff from moving between the south and the north of the strip. The planed activities were achieved namely, training for law enforcement agency staff and health professionals. In the process of objectives' implementation, some challenges were ironed out. The main challenge was the continuation of the instability in the political situation. The Gaza Strip continued to be divided in two main parts (South and North). These measures restricted the movements of GCMHP beneficiaries in particular and the total population in general. The frequent attacks by the heavy-armed soldiers infuriated the situation. This permanency of these living conditions repulsed the majority of international teachers and thus minimizing their contribution to the capacity building activities. The report highlights these challenges, the effects of the political situation on the project in particular and describes the alternatives used to overcome these challenges.

1.1 Postgraduate diploma

Twenty eight (16 in the first year (started 2001) 12 in the second year (started 2002) participants are currently joining the diploma. In November 2001. More than 120 applicants applied to the diploma course. It worth to mention that the female male participants is increasing. When the diploma started the ratio of male to female applicants was 4:1 in the year 1998. However in the year 2002, the male to female ratio improved to 1:3, which is a considerable increase compared to the previous intakes. This is a major achievement since the male-female ratio is one of the biggest challenges facing us at the moment. This challenge has its cultural roots; females usually get married and are then not allowed to continue education, except those who are in good economic situation. Another reason is that the field of mental health and psychology is still a stigmatized. More than 135 applicants applied for the year 2003.

With the Dutch support, a new system was introduced, the scholarship and loan scheme. The funds generated will be used for future trainees' scholarships. The students signed contracts based on the new scheme. The terms of the contract indicate that students have to pay back half of the scholarship that they receive and that they will work in Palestine for a minimum of two years after finishing their studies. Using such fruitful system more poor, refugees and females were given the opportunity to further their education.

It is worth to mention that when the diploma started in 1997, students are asked sign contracts of staying in Gaza when they finish their studies. The main emphasis was to avoid "brain drain". The new contract stresses on both "brain drain" and the loan.

In the 2002, the majority of the theoretical modules are taught by the local teachers who are increasingly involved in teaching and gradually took over work responsibilities of international teachers.

1.2 Students' Practical placements
The students are offered practical placements through GCMHP's clinics and facilities, which are distributed in the Gaza Strip. They were grouped and allocated to the 4 community mental health centers (Gaza, Jabalia (north), Deir EL-Balah (middle) and Khan Younis (south). The students were assigned to the multidisciplinary teams according to hourly plans. Students are divided into groups and each group is doing practical placement under the supervision of the local trainer at the GCMHP's clinics. Group supervision occurs once a week.

However due to the impediments on movement within Gaza strip distributing the students evenly on the four clinics was not possible because the majority of the intake is from Gaza and the northern governorates. Thus the clinics of Gaza and Jabalia sustained the heaviest share approx 85% of the students.

2. Counseling and mental health for Midwifes course The second course of this pilot project directed for midwives took place in July 2002 till Jan 2003 in partnership with the Mental Health Society (Palestinian NGO) in Khan Younis. since the southern municipalities are in great need for such training. On the other hand the current political situation and it is consequences on the ease of movement between southern and Northern part of Gaza strip. Therefore it was decided that the second course is to take place in the southern municipalities. To assure the performing of the course at GCMHP standards, required that the course is to be made with a specialized institution that can contribute with not only the training space but also with the qualified trainers. Preparation for the course started in June, an invitation was sent to the Khan Younis General Hospital and the European Hospital to nominate midwives to participate in the course. The findings of the needs assessment performed last year were implemented in the design of the new course.

2.1 The impact of the course A pre and post questionnaire have been applied to asses the impact of the training course. The curriculum of the new course was modified based on the findings of the assessment of the one before. The results of the feedback assessments will be presented in the year 2003.

3. Courses in mental health and human rights for professionals from the health social sector.

The course aims at providing the participants with basic counseling skills, home visits and how to help the victims of Intifada and their families, and the right to health concept. All lectures and training sessions were conducted by local trainers of the GCMHP. The course content, its validity to the participants' day to day activities was evaluated. The result of the evaluation is highlighted in appendix 6. In summery, more than half of the participants agreed that the course content is suitable to their day to day activities. When they were asked about the time of the course almost half of the participants indicated that the course period was not enough and more time have to be applied in the next courses

1) The evaluation of the course contents was very satisfying (very good 66.7%, 33.3% good).
2) The course content was appropriate to their work scope (Very good 26.7%, good 73.3).
3) Trainers' evaluation (at very high quality level 46.7%, at high quality level 53.3%).
4) Training material evaluation (very good 46.7%, good 53.3%).
5) The course content would improve their working performance (Very good 20%, Good 46.7%).
6) The students' participation was good and beneficiary (very good 33.3%, good 60%).
7) Approval of the course duration (Very good 60%, good 40%).
8) The course level exceeded their anticipation (Very good 60%, good 13.3%).
9) Each module was clear and the syllabus was aligned with the aim (Very good 46.7%, good 46.7%).
10) The course was very practicable and the live practice added to the theoretical material (Very Good 66.7%, good 13.3%).
11) The trainers had relation with the participants (Very good 66.7%, good 26.7%).
12) The trainers allowed for questions and responded in a very good way to them (Very good 73.3%, good 26.7%).

4. Prevention of torture and promotion the human rights Despite of the current political situation, we were able to accomplish the planned activities. The lessons learned from the courses given in 2001 were reflected on the contents of the modules given content.

Over 2002, four courses in mental health and human rights were conducted. Each course composed from 15-20 participants selected from both the Intelligence Agency and the Preventive Security forces was completed. The course started on the 12th of May, scheduled for three weeks. The course contents covered areas related to the area of mental health and human rights, psychology of victimization, human rights abuse torture and the role of law enforcement agencies, problem solving approach (win-win approach), basic communication skills, and the role of NGOs in promoting and preventing human rights abuse and other areas.

4.1 Impact of the courses: The course impact and evaluation have been in depth and would be reflected on the course content of the upcoming two courses on trial bases. The evaluation results are as follows:

1) The course content was appropriate to their work scope (Very Good 50% & 57.1% and Good 40% and 42.9%).
2) Trainers evaluation (Very Good 60% & 64.3% and Good 40% and 35.7%).
3) Training material evaluation (Very Good 70% & 57.1% and Good 30% and 42.9%).
4) Course content would improve their working performance (Very Good 60% & 50% and Good 30% and 50%).
5) Students' participation was good and beneficiary (Very Good 70% & 71.4%, good 20% & 28.6%).
6) Course duration. (Very good 20% & 21.4%, good 40% & 42.9%) The majority of both courses requested the elongation of the course duration, by adding the practical component.
7) The course level exceeded their anticipation (Very Good 50% & 78.6%, good 20% & 21.4%).
8) The trainers had very good relation with the participants (Very Good 80% & 71.4%, good 20% & 28.6%).

4.2 Field visits:
Random selected sample of former participants of the courses was visited in their fields of work to get feedback of the course's implications in their work and the challenges they face. The major challenge faces former participants was the general political situation. We visited training department at the intelligence department for feedback and future planning. Although the intelligence department monitors and follows up the former trainees, we agreed that the field worker will visit the working places for semis-structured interviews. We are at the present in the process of designing the tool.

4.3 The Recommendations from the participants.
a. Increase the Personality related issues with special emphasis on (Personality Characteristics - Personality goals).
b. More focus on crime related issues specially (who to deal with criminals - crime motives - criminals treatment methods)
c. Increase the community mental health portion on the account of the police methods portion.
d. More concentration on the Human rights issues.
e. Investigate the possibility of adding a practical component to the course.
f. Increase the course duration to 6 weeks instead of the current three.
g. Give more emphasis to psychological methods to handle criminals to replace torture.

5. workshops for community health and allied professions
a. workshop on human rights cross cultural perspective with emphasis on the Palestinian culture. One of the feedbacks received from various courses given, is that the Human rights is a Western Concept that does not match with the Arabic cultural and the religion. Therefore a two-days workshop was organized by the for the Diploma students and human rights activists. The theme of the workshop would be the compatibility of Human Rights as a Western Concept with local culture principles and the religion.
b. The training department held a two days workshop on "The Community Mental Health Act". Around 30 participants selected from GCMHP, several related NGOs and the Ministry of Health attended the workshop. Mr. Abdel-Hamied Afana presented a Paper on the issue. A committee was formed as a result of the workshop. This committee is chaired by one of the Diploma Students (Dr. Amjad El Shanti ) the duty of the committee is to follow up on the implementation of the first workshop recommendations with the various entitled agencies and to organize for a second workshop in Dec 2002 or January 2003 to decide the actions to be taken to strengthen the Act and to assure its full implementation in the future.
c. A workshop aimed at community mental health approach to handling the Palestinian Youth tendency to become Martyrs. The workshop was in coordination with all the local NGOs that work in this field and the Governmental Organizations (namely the Ministry of Health, Ministry of Social Affairs and the Ministry of Ex-Prisoners and Detainees)
d. On the Other hand, the GCMHP professionals have participated in the organization of and participated in three workshops during. The three workshops were under one subject "Torture is a Crime against Human Rights", following are more details about each work shop:

6. Practical placements for students and Professionals
a. Training and Education Department offers to students from universities and institutions short term clinical and community placements. Because of the political situation, regional and international students were not able to come to Gaza. However, The training department in co-operation with the team leaders of the clinics have designed a daily time schedule to accommodate the students from different local universities, colleges and schools. These arrangements should also be seen as part of the networking activities for the GCMHP i.e. to build relations with other organizations and institutions through practical work and exchange of experiences. 20 students have done their practical placements in different GCMHP units. El Azhar University, the Islamic University-Gaza, Al Quds Open University.
b. For the first time, Al Quds university Faculty of Medicine, sent four medical students to do their practical placements at the GCMHP clinics. The oral feedback generated from the participants in the presence of the faculty representative (Dr. ) was excellent. The only request from the participants was to increase the period of their practical placements yp to 5 weeks instead of three weeks.

7. Cooperation with other organizations. The training department has successfully achieved strong networking and working relations with various agencies. Following is a list of the most important networking achievements of the training Dept.
a. Networking with Ministry of Education and UNRWA. In 2001 a partnership agreement was signed with the Ministry of Education according to which GCMHP became responsible to execute the MOE plans to train and upgrade the School Counselors.
b. UNRWA accepted to train its school counselors through GCMHP. The school counseling training is funded through the Crisis Intervention Program.
c. The human rights courses for the police forces have assisted in creating strong working relation with the Palestinian Intelligence Agency. Several cooperation scenarios are under discussion at the present. Details would be given regarding any agreements reached.
d. The training department growing reputation as a professional training institute has resulted in receiving requests from several NGOs for training on issues related to Community Mental health and Psychology. Off these NGOs are the Association for Al-Azhar University Graduates and Al-Shate' Friends Association. Due the unavailability of funds, neither under the Capacity Building nor the unrestricted funds, these request has been deferred until a suitable funding source is established.
e. A meeting with the Minister of Health was held in March 2002, aiming at following up the implementation of the plan of improving mental care into primary health care clinics. The Ministry of health has not until now assigned any training activities to the Training Department. In addition, a policy of buying mental health services from the GCMHP is under design. The same arrangements would be implemented with the UNRWA.
f. Mministry of health invited GCMHP to assist in redoing the course for GPs working at the Paediatric Hospital. The main theme of the meeting was the course syllabus. The input of the GCMHP was discussed in terms of providing trainers and consultation on the main themes of the syllabus. The ETD re-stressed the importance of community approach to mental health problems mainly children and caregivers, the importance of adding a module about child rights, child abuse, and the role of parent in promoting a democratic environment.

8. Develop Training and Education Department to an efficient regional learning institute providing training based on values of justice and respect for human rights for Palestine and the Middle East through furthering cooperation with local, regional and international universities.

a. In Jan and Feb 2002, a series of meetings with representatives from local universities was held to discuss the advantages, disadvantages, vision, activities and the process of developing the ETD scope of services. The participants were selected from the four universities in the Gaza Strip. The aim of these meeting was to analyze the needs and aims of any new courses to be implemented. On the other hand according to the objectives of the program is to establish the regional training institute for Community Mental Health. A special mission from the Netherlands to evaluate the needs for the establishment of the Institute was planned in April 2002; however due to the current circumstances the mission was delayed until Oct 2002. The results of these discussions and the findings of the special mission will be presented in the upcoming academic board meeting.
b. From 27-29 October 2002, Professor W. H. Wolters and Dr. Jan Krapels as a team dispatched by the Dutch Ministry of Foreign Affairs visited GCMHP. Their visit comes a part of the cooperation between the Dutch Government and GCMHP in establishing an institute of community mental health. GCMHP's PR Director, Husam El-Nounou, conducted the following interview with them.

Let us start by introducing yourself and the purpose of your visit to GCMHP.

Prof. Wolters:
I'm Professor Wolters from the medical faculty at Utrecht University in the Netherlands. I work in the field of child and adolescent psychology. I have been with GCMHP since 1995, as one of the people that helped develop the community mental health diploma. Later, I became a member of its academic board. I'm still a member of the board and a member of the board's managing team. Dr. Krapels and I were invited by the Dutch Ministry of Foreign Affairs to examine the situation, especially the training department in relation for funding over the next 3 years.

Dr. Krapels:
I am Jan Krapels. I'm a consultant to the Dutch Ministry of Foreign Affairs. As Professor Wolters said, we are asked to report on the development of the Programme in order for them to take a decision for continuing to support it or not. Professor Wolters is a member of the academic board and that is his main topic of interest. And my part of the job is the organizational development of the project and the development of the organization as a whole.

You mentioned the general objective of your visit. Would you please elaborate on that?

Dr. Krapels:
I'm impressed by what has been done over the past years, especially in relation to the conditions that you are in. What we see is that the organization is developing very fast. And that is Ok because it is needed. There is a huge need for your expertise and for your organization. On the other hand there are the problems of an organization that is developing fast. And this is what we are discussing with you individually and in groups.

Prof. Wolters:
I would like to add that I have been coming here for years, with strong motivation and pleasure. And after our recent interviews with the staff, I'm impressed with the high quality of the Programme and its people. I think this is a very important institute. In the field of mental health, it is rather unique in the Middle East. This is not a kind word to you. It is our deep conviction and experience. I think that investing in this institute over the next years is very important. After peace is established, there is a lot of work to do like restructuring and building up society.

In a broad sense, I think that the contributions of this institute, not only in the field of mental health but also to the social institutions in society, is very important. This is a message we give to the Ministry of Foreign Affairs in the Netherlands, who are themselves convinced of the things I said. The Dutch Government is very interested in this institute. As you know, when a Dutch Government Minister is in this part of the world, they come and visit. We talk to people on the political level about the institute and they want this institute to increase in capacity.

Question: How will the institute contribute to society?

Prof. Wolters:
The level of organization and transparency of structure is very important. Also, leadership is very important. Dr. Eyad is a brilliant man. He is a pioneer. He established a Programme that is unique and known in Europe and the rest of the world. But now there is a new stage, so organization and leadership are needed. And your contacts with society are intensive. Yesterday, we visited the Ministry of Education and Islamic University. So you have a network. In the future, it is necessary to enlarge this network to connect the most important people in society to your work.

Professionally, there is no problem. You have a very good group of professionals here. You have a group of international professionals who are not only colleagues, but friends who want to contribute when you ask them. So this point of view is covered. There is a need for structuring and the need to connect society and to build a stronghold. Then there is the dream of the institute, which is fantastic.

Dr. Krapels:
This institute has a specific place in your society. What we heard at the Ministry of Education, Ministry of Health, and Islamic University indicates that they recognize this important position. And they asked that this institute become part of the network of your society. I agree with that too. Without losing your identity or your professional strength, you can be a really important party in your society. And I think that that is another obligation you have as an institute, to serve your society.

Prof. Wolters:
And I would also add that the combination of patient care and excellent training is a very good combination. We should hold on to that and develop it.

What steps are necessary to be taken in the future for the establishment of the Institute?

Dr. Krapels:
The first thing is that we have to report to the Dutch Foreign Ministry on the next phase in the development of this Programme. As Professor Walters said, we are convinced of the combination of training and medical services and the research department. Those are the three main issues in this organization. They have to develop to become a strong base for this institute. And for the long-term, this is what we see happening as far as our opinion is concerned. We want to point out to the Ministry that this kind of strategic thinking is very important.

Prof. Wolters:
And at the same time we are thinking how you can cope with the actual situation. You don't just get patients. But the workers in this institute are also suffering from what I call this "war situation." So this is extra stress for the workers of the institute. This is quite heavy. You have to help people but at the same time you are under siege yourselves. This is very important. And I think this is very important to bring it up in your teams and reflect on it in your work.

What are your impressions of the visit and how do you see GCMHP in comparison with similar organizations in the region?

Prof. Wolters:
I have experience in the field of mental health in many countries. And I am impressed by the way how mental health work here came up on a high professional level in a very short time compared to many other countries. Sure, there are many things that need to be done. But this has more to do with time and people and investment rather than the quality of the people. And I have a lot of trust in that.

As to the training program, we are astonished to see that it is at a very high level in such a short time. I am impressed that you could do this at a time of external and internal problems, and with many professionals unable to come from abroad. I'm impressed that there was a lot of organizational activity. So by force, you have become in a sense independent. This is an indication of the strength of your organization. But at the same time, I think that developing this Programme and building it up for the future (and we should be very modest about the dream of an institute for mental health), we need to work together with a lot of parties and go on. But I'm glad to see what I see.

Dr. Krapels:
And as far as the organization is concerned, what we see here is what you see in most fast-developing organizations. But you also see severe circumstances that you have to cope with. And that makes it more difficult and more impressive for us to see what you were able to do. At the same time as professionals, you need to develop an organizational structure that makes it work in the future also.

Continually, there is the struggle between professionalism on the one-hand and organizational structure on the other hand. For professionals, organizational structure is less important because they are heavily involved in their work and in the problems they meet everyday. But at the same time we need to understand the need for organizational structure. And what we try to do here now is elaborate on that because there is a firm basis. But now we have to develop on that basis.

Prof. Wolters:
As a professional with interest in the organizational aspect, I have had this discussion in our university hospital. And this discussion was conducted in the Netherlands on many professional domains. This is a professional organization and good management is important. But management should support the professionals to do their work well. And professionals need to understand the need for modern management techniques. So if you could find a good balance between these two elements, it would be very good for the future.

Q: How do you see your role in the development of the training department and organization as a whole? And what do you think that friends of the Palestinian people should do the success of such an organization?

Prof. Wolters:
First of all, I'm waiting for the moment that teachers from abroad can come in. I have a friend who would like to come but his wife is anxious because of the situation. So, we hope that they can start to come very soon. With regard to the short term, Jan and I will make proposals to the Programme. Our suggestion is to come back in a few months and put some proposals for you on the table on which you can work on the organizational front. And then we will meet to discuss the future of the academic board which can be very good support for the head of the training department and the clinic. And then we will see how we will go on. So, we have a short-term approach and then we will see how things will develop with the new director-general.

There are changes coming on in this organization; and we need some stability in the area. For us, that facilitates more interaction and people coming. From a professional point of view, we need to find out what new needs are there and which areas we should go in and what new theories and techniques we should bring in to the students in the program. And we are dreaming of more exchange with universities.

I was very eager to come here. I wasn't here for one and a half years. I told my wife that I am very glad to go (like a young boy who for the first time goes to Paris). And we feel at home here. We feel part of the family of GCMHP. And we are grateful for your hospitality.

Dr. Krapels:
This is my first visit. And I'm very impressed in many ways with what I have experienced here and what I met here. In this programme, I'm impressed by your hospitality, but also your professionalism and by the courage you are showing by continuing to work in this hard situation. And I'm impressed by the openness we have had in all our discussions here. And we hope to contribute our small share in strengthening your institute and improving your situation.

In Dec 2003, GCMHP organized a workshop (details are provided in the narrative report for July till Dec 2002) to discuss the organizational strategy and questions of organizational development for the coming three years. GCMHP Director, the heads of the professional departments, the heads of the administrative departments, several projects officers, Dr. Wolters and Dr. Krapels participated in this workshop. Among other issues discussed was the development of the Organization Objectives and the need for the adoption of long term planning by the departments and the reallocation of the departments into separate premises for each. It was decided that the departments are to be given until mid Jan 2003 to develop their respective 3-years plans. It was also decided that the departments' reallocation is to be executed by Mar 2003. On the other hand each of the departments is required to perform in depth assessment of the executed activities in the past 3-years. The Participants in the workshop agreed to meet later in 2003 to assess and merge the approved the long term plans of the departments into organizational long term plan.

9. Lessons to be learnt One of the major external obstacles is the continuing political situation and its consequences which have negatively affected the work of GCMHP since the beginning of October 2000. It has not always been possible to travel within the Gaza Strip, because of temporary sectioning of Gaza regions. Therefore the policy of clinical staff temporarily allocation to the clinics that are closest to their living places continued. Despite all the restrictions of movement and the difficulties for daily life, which come along with the current conflict, the training department managed to carry out all planned activities. Some of the lessons that were learnt during this period include:

1. The courses, for low enforcement agencies mainly the intelligence department, were a great opportunity to raise the people awareness about the links between mental health and human rights and the feed back gained from the field visits has proven this. However when trying to make the course jointly between representatives of two different agencies (The Intelligence and the preventive security), the level of success has deteriorated because representatives of the two agencies failed to work as one team. Thus in the future we are think of evaluating the need for preparing courses for the officers of various agencies to learn how to work as a team and overcome the barrier of being in rival agencies

2. Inviting decision-makers of the intelligence department to participate in both the planning and the implementation; moreover in reflecting the feed back gained from the evaluation from the previous courses has assisted in elevating the content of the courses and their impact.

3. In politically unstable regions like Gaza, emergency plans with different alternatives have to be always ready in order to assure tasks and activities accomplishment.

4. Although the diploma program was well organized and the foreign professors were contacted long before the time of their modules the current circumstances have prevented most of them from coming thus the development and the dependency on local trainers should be increased.

5. The debate about human rights as a western concept in comparison to the Arabic and Middle Eastern social norms and culture is still unsettled.

6. With the presence of the diploma, the various training courses and the increasing demand from the post graduate students and the general population on community mental health and human rights related issues.

Summery Accomplished training activities 2001