Mental health disorder constitute one of the largest and least acknowledged health problems in the occupied Palestinian territory (OPT), Around a third of Palestinians are in need of mental health interventions, yet mental health services are among the most under resourced areas of health provision, This article explores the scale, nature and causes of the mental health problems confronting Palestinian men, women and children in the OPT, it argues the case for a comprehensive mental health plan that involves all relevant community institutions. Policy makers and health planners must genuinely and clearly adopt a community mental health approach to tackle the overwhelming, and increasing, mental health problems being experienced by the Palestinian population. This should include both therapeutic measures to expand and improve diagnosis and care, and efforts to address those factors in the political environment that contribute to mental ill-health

Mental health in the OPT
As through out most of the Middle East, Palestinian culture has its own traditional explanations for mental disorders. The common belief is that mental illness is the result of possession by supernatural forces. This possession has religious roots, and cannot be explained in psychological or psychiatric terms. In many developing countries, Palestine included, mental disorders are often a source of fear. In some cases, this leads to rejection of the mentally ill. Because illness carries a stigma, patients tend to present emotional or psychological distress in the form of physical symptoms such as headaches, colic and back pain. This suggests that the extent of mental illness is being significantly under reported. Health workers have only recently begun to acknowledge the political and environmental factors involved mental ill- health.

The Palestinian population has been exposed to a series of traumatic events, including imprisonment, torture and human rights abuse, demolitions, land confiscation, movement restrictions and the indignities of unemployment and under-employment. Wages are low and travel hour's long, reducing family time. Land confiscation in particular is a source of much frustration and tension, while house demolitions, used as a collective punishment by the Israeli army, can have an immense psychological impact. The home is not just a shelter, but the heart of family life. Losing one's home is traumatic experiences associated with being a refugee. Shelling of Palestinian areas and the demolition of Palestinian losses in the 1948 war, a particularly acute and deep-seated source of fear and insecurity. A adults who are exposed to house demolitions show a higher level of anxiety, depression and paranoia than other groups.

As men lose faith and confidence in the face of their traumatic experiences, women often bear the brunt in physical abuse. Up to a quarter of Palestinian women in the Gaza strip have been exposed to domestic violence and abuse at some point in their lives, mainly from their blood relatives and husbands. Women also exhibit a higher prevalence of mental disorder than men. One explanation for this could be to do with how the conflict has changed women's roles in ways that are often very difficult to accommodate. Traditionally, Palestinian society was authoritarian and patriarchal, with the advent of the intifada, however, women have been politically active alongside men. The structure of Palestinian homes has also changed because husbands are often absent, whether for work in Israel, in Israeli detention or dead, or suffering from the effects of trauma.

For children, the psychological effects of violence are severe and traumatizing. While many injured children have acquired a permanent physical disability, many more have developed psychological impairments. The prevalence of neurotic symptoms and behavioral problems among children, such as disobedience or irritability, is high. According to recent research in the Gaza Strip, some 32.7% of children suffer from severe levels of post-traumatic stress disorder, 49% moderate levels and 16% low levels.

The state of mental health care
Mental health care is provided by the government, and by the non- government al sector. Government provision is offered though the Bethlehem psychiatric Hospital in the West Bank, which has a bed capacity of 320 patients, or whom 30% are chronic epileptic patients. Gaza Hospital, established in 1979 and rehabilitated in 1994, has 40 beds. Both hospitals use a traditional biological approach, with conventional pharmacological therapies.

And, at Bethlehem, electroshock therapy. However, patients and their families tend to lack confidence in mental hospitals, which are usually seen as custodial institutions in which troublesome and frightening people are sequestered.

One of the few non-governmental and non-profit organizations working in this field is the Gaza Community Mental Health Programme (GCMHP). The GCMHP adopts a community-based approach the whole Gaza Strip.

The GCMHP offers Community and clinical mental health services through its multidisciplinary teams, produce research studies, publish articles in international journals, and gives training courses in community mental health. It has established a postgraduate diploma in community mental health and human rights that is unique in the Middle East. The GCMHP also offers special services for women exposed to domestic and political centers;

Other mental health service providers include:
• The Shamas Center, which supports rehabilitation initiatives for brain- damaged or severely handicapped children.
• The Union of International Churches;
• A small network of psychological support and counseling services comprising the Union of Medical Relief Committees, the Palestinian Counseling Center, offering programmes for children and young people;
• A Medicines Sans Frontiers center for the support and rehabilitation of political prisoners in Hebron, in collaboration with the Ministry of Social Affairs, plus cooperation activities with Terre des Homes for psychological assistance for infants; and
• A Programme of rehabilitations support in Hebron for chronic mentally-handicapped patients.

Meeting the mental health needs of Palestinians
To meet the growing mental health needs of the Palestinian population, a comprehensive mental health plan involving all relevant community institutions is crucial. A first step would be to integrate mental health services into primary healthcare. This will increase access, reduce stigma, increase acceptability and strengthen monitoring and information systems.

It is also a more cost-effective approach, since the premises and staff would already be in place, and specialized psychiatric staffs are very expensive.

Second, health professionals working in primary care and social welfare services should receive training in mental health issues. In particular, there should be more emphasis on training primary healthcare professionals and school counselors on the early detection of mental health problems.

Third, the existing community mental health services should be strengthened, and their initiatives supported.

Mental health needs to be 'de-institutionalized', and inter-sectoral collaboration should be improved, both within health services and between the health sector and allied professions and community institutions that contribute directly or indirectly to health and ill-health, such as law enforcement agencies, schools and religious institutions. Finally, there is a need for political action to ease the environmental factors that contribute to mental problems, by pressing politicians to resume peace talks and end the occupation.

Abel Hamid Afana is a clinical psychologist and director of training and education at the GCMHP.

Samir Qouta, also a clinical psychologist, is head of the GCMPH research department.

Eyed El Sarraj, a psychiatrist and human rights and peace activist, is the founder and chairman of the GCMHP.

References and Further Reading

Ihsan Al-Issa (ed.), Handbook of Culture and Mental Illnes: An International Perspective (Guilford, CT: International Universities Press,1995).
Abdel Hamid Afanal et al., 'The Assessment of Mental Disorders in Primary Health Care Clinics in the Gaza Strip', Primary Health Care Research and Development, 2003.
Abdel Hamid Afana et al., 'The Ability of General Partitions To Detect Mental Disorders among Primary Care Patients in a Stressful Environment: Gaza Strip', Journal of Public Health Medicine, 24 (4),2002.
Abdel Hamid Afanal et al., The Attitude of Palestinian Primary Health Care Professionals in the Gaza Strip Towards Mental Illness', Egyptian Journal of Psychiatry,23 January 2000.
Abdel Hamid Afana, A Community Based Approach Mental Health, MA Dissertation, Bristol University, UK, 1994. M. Dwairy and A.de Gruyter, Cross-Cultural Counseling: The Arab-Palestinian Case (New York: Haworth Press, 1998).