Tortured past: Caring for Palestinian torture victims has been a challenge for mental health workers in Gaza.

Abd El Hamid Afana

The actions of the Israeli government and resulting Intifada activities have devastated the lives of ordinary people in Gaza and the West Bank. The occupying forces have arbitrarily arrested and tortured people, leaving thousands of Palestinians suffering from posttraumatic stress disorder. Thousands are still languishing in prison.

In reaction to the Palestinian struggle for independence, the Israeli Defense Force has arrested and tortured thousand of Palestinians as well as imposing collective punishment measures. These have included curfews, which sometimes lasted up to 40 days, isolating, families and friends. Children have suffered the most under these abnormal conditions.

As a response to this vast need, mental health workers have looked to the established models of community based mental health care. In this approach, the emphasis is shifted from the segregated and self – contained health care system within institutions to community .The role of the mental health professional must be changed from that of provider of health care to facilitator in order to enable individuals to solve their problems using the resources of the family and community institutions.

By learning from existing experience in this field, the community movement in this field, the community movement in Palestine has put psychological problems into their wider social, economic, political and environment context and tapped into the experience of the community to address its needs.

All kinds of psycho- pathologies needing professional mental health help exiting in Gaza. Since 1967, approximately 400.000 Palestinians have been imprisoned out of a total population was 750,000. The rest of the population has been exposed to night raids, beatings, home demolition, and/or witnessed the violence of killings.

Evidence of distress

Research about the extent of post traumatic stress disorder symptoms following imprisonment of Palestinians in Israel was carried out by the Gaza Community Mental Health Team in 1992. Interviews with 477 ex-political prisoners who had each spent between six-month and 10 years in prison showed widespread difficulties. One in four (41.90%) found it difficult to adapt to family life. Nearly half (44.7%) found it difficult to socialize, one in five (20.1%) have sexual and marital problems, and three quarters (76.5%) have economic difficulties.

Social stigma

As in most Middle East countries, Palestinian culture has a traditional way of dealing with mentally disordered people. It is commonly believe that mental disorders are “ evil spirits” or “evil eyes” called “ a-fa- reet” in Arabic. The traditional healer is the only person able to extract the (a-fa-reet” from the human body. An amulet, which contains some, verses of the Holy Qura’n is traditionally prescribed. The amulet is a piece of parchment with religiously significant words and symbols which is worn as a necklace.

Mental disorder are highly stigmatizing and suffers perforate seek help of traditional healers or present their psychological symptoms. Being identified as a mental health client causes many difficulties in Palestinian society not only for the patients but also for the family. Sadly, if a woman has a mental health problem, she and possibly her sisters would be considered unsuitable for marriage.

The problem of stigmatization is even worse among ex-political prisoners. In the view of the Palestinian public, these individuals return as heroes and should not have psychological problems. These belief result in the denial of mental health problems and we have found that ex-political prisoners are using denial as a mechanism of defense in order to establish a state of psychological balance.

The denial is supported by the community in many cases and has its advantages: s/he will be celebrated as a hero and will have opportunities not available to others. But there is no room for complains; those who were able to withstand the torture by interrogators must not complain. For example, in an informal setting a former political prisoner said, “I have no psychological problems” while we were talking about his prison experience, however, he declared that it was difficult for him to take a shower after seven in the evening. This reminded him of his times in prison when the Israeli army forced him to take a very cold shower in the middle of the night.

In response to the overwhelming mental health problems among the Palestinian population, the Gaza Community Mental Health Program (GCMHP) WAS ESTABLISH in 1990. The director and staff 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.

We set out two main goals. The first was to reach as many people as possible –many of them reluctant to receive psychological help – with a very limited number of professionals. The second was to address the stigma of mental problems by changing the attitudes of Palestinian society towards psychological disturbances and those seeking treatment and raise the awareness about mental health problems.

Reaching out

Our outreach program has two main components based on the principles of community care in which health professional become facilitators and the community gets involved. By training ex-political prisoners to be peer counselors we have found we can tap into the community and its experience of torture. These counselors are better able to understand the problems encountered by former political prisoners than professionals are. They can communicate more easily with prisoners, listen to their problems and convince them to seek help when necessary. The health professionals act as their supervisors.

Group therapy allows us to increase the number of people we can reach. The staff has been trained in-group work cooperation and competition personal development conflict resolution decision-making skills and other issues related to daily life. At this point it as not connected to mental health.

The size of the groups varies but the members are strangers to each others, allowing free expression. The membership is drawn from the community most of them former prisoners who are working in a variety of community settings. It seems to be the ideal approach especially as many of our employees are ex-prisoners. The group is a safe place where each member learns to move from the first stages of anxiety suspicion and mistrust towards trust and openness.

Our approach has been based on the concept of improving relationships between people: between employers and employees: between husband and wife: and between family members. Any form of coercion or trying to force people to talk is definitely out of the question. Group theory is bad on very strict principles of selection and voluntary participation of individuals. Each member is given the space and time and his own authority to verbalize when he or she feels safe. The group setting gives the clients and us the possibility of using time to talk about their problems.

We have also run community education campaigns about mental health targeting women, students, professionals, former political prisoners and religious leaders. We hold them in community setting such as mosques, schools or simply under trees and starts by talking about general health then moving into mental and illness.

Spreading the word

By running short courses and workers, we have been able to spread the word able to spread the word effectively through the community.

I believe that our approach could be used in other settings where people have suffered mass oppression. For example, the South African and Palestinian people have had a similar experience of political oppression and change. In Gaza and the West Bank the occupying forces denied us every form of professional education opportunities. We were left with only a few professionals who are trying to serve the demands of the masses beyond their capacity. I see the same situation being repeated in South Africa. Three hundred years of racial discrimination have delivered overwhelming psychosocial problems, mass distrust, and other psychopathologies. There is enormous potential for cooperation between the two peoples in the mental health field.

A community in crisis

Abdel hamid afana outlines the experience of the Gaza Mental Health Program in Palestine

Palestine has a desperate need for community mental health services. Not only is Palestine experiencing rapid social and economic change, but it has undergone long periods of military occupation by the Israelis, with a subsequent uprising (the Intifada) and, in turn further repression. All of these factors have affected the mental health of the Palestinian people.

Palestine is now gaining some political autonomy, with the new Palestinian authority taking responsibility for health and education. It is obvious that mental health care should not, and cannot, be provided by a few specialists or by large centralized institutions .The new authority now has the opportunity to consider adopting a new type of service based in the community.

The Gaza Community Mental Health Program was established in 1990 to respond to the overwhelming in Gaza. Around a million people live in this small area, mainly in refugee camps or makeshift shantytowns. The area is frequently sealed off from Israel and the rest of Palestine The population, half of whom are under 15 years of age, has experienced curfews and night raids, seen houses being demolished, people being beaten, killed and imprisoned. In these circumstances, it is difficult to build relationships based on the trust, confidence and openness that facilitates good mantel health.

Spreading skills

Our program attempts to overcome the lack of existing mental health care services through a community –based approach. Our three centers offer services ranging from clinical services, drug treatment and psychotherapy. Each center has a multi –disciplinary, nurses and a social worker, who also conduct home visits in addition to their work in the center.

We carry out training to spread mental health skills in the existing health sector by providing courses and workshops for workers in primary health care clinics. We also work directly in the community.

In Palestinian society, people with mental health problems face many prejudices. The traditional explanation is that an evil spirit, called a-fa-reet, and that only a traditional healer can extract the spirit from the body causes mental illness. People try to protect themselves against a-fa-reet, and that only a traditional healer can extract the sprit from the body. People try to protect themselves against a-fa-reet by wearing amulets containing verses from the Koran (the Muslim Holy book). Many Palestinians, including educated professionals, continue to hold these views, even though they may not express them openly.

Through community outreach aim to reduce prejudice and stigma and raise awareness of mental health. Traditional views and structures (such as male dominance and tribal authority) can present obstacles. Therefore, we have approached community leaders, such as traditional healers, religious and tribal leaders, in informal settings, listening to what they have to say and explaining what we are trying to achieve.

In one case, we approached the traditional leaders of a village in rural southern Gaza and discussed how to increase mental health awareness in their community. They suggested it was better to start indirectly by talking about general health issues and arranged for me to talk to group of women on the subject of children’s health.

At the women’s request. I talked of the effects of intestinal worms and gastroenteritis. At our second session, I talked on dehydration and then introduced the topic of child behavioral problems. The women then asked for a discussion on bedwetting, aggressive behavior and disobedience among children. After five meetings, the women told me that they wanted to begin to discuss the problems they were experiencing as women.

The women talked of the Intifada, the curfews imposed by the Israeli army, imprisonments and beatings, and the psychological effects upon them –stress and trauma- related symptoms –physical and emotional abuse. To hear the women talk openly on these subjects was an exciting experience and it filled me with hope for the future.

In Gaza we have had to start from the beginning, by contacting and educating people about the concept of mental health. Services can only begin when people understand and accept what is being offered.