Violence does not only leave visible traces but also affects the inner lives of people, their interpersonal relationships, the social structure they live in and the collective’s sense of self. Trauma through violence is a humanitarian issue in the sense that it creates psychological diseases just as physical ones, but it also carries implications for any future attempt of conflict transformation or state-building. Mitigating traumatisation is a humanitarian responsibility for international and local actors, but talking about post-traumatic stress disorder (PTSD) in Palestine implies the danger of de-contextualising the effects of violence on the population, as well. It gives the image of a universally applicable diagnosis, independent from the context that triggered it, which creates the illusion of manageability through clear intervention strategies and decisive medical prescriptions, rather than political solutions and social change. This further implies the danger to dedicate to alleviating symptoms, by softening the impact of occupation, instead of actually addressing root causes. This paper aims at analyzing PTSD in the Palestinian context, the way it is and could be dealt with by local and international actors and its implications.

The Trauma Context

At the individual level, the most extreme psychological reaction to the experience of violence is post-traumatic stress disorder (PTSD). It is caused by an event, which is so overpowering that it overwhelms the psyche’s usual coping capabilities and cannot be processed as usual. It becomes detached from the coherent life narration and cannot be stored in the memory as past event, meaning that from time to time it breaks into the consciousness as painful presence. Traumatisation has a profound impact on an individual’s cognition, emotion and behaviour. Trauma is, however, not a quality inherent in a violent event itself; it rather refers to the meaning of an event to the concerned individual. Some events might be extremely shocking for some but not for others, according to their individual and collective experiences and mediated by his or her psychological capability to deal with it. In the case of the Israeli occupation, violence rarely is a one-time experience; there is hardly a post-traumatic situation, because violence is recurring and ongoing on direct and indirect levels.

In Palestine direct and indirect violence is ongoing for more than 60 years. Direct violence is carried out by actual actors as in bombings, gunfire, teargas, destruction of homes and resulting displacement, destruction of infrastructure, arbitrary detention and torture. The impact of this direct violence becomes visible in the following quantitative data: From 2000-2011, 6,379 Palestinians were killed by Israeli security forces in the West Bank and Gaza Strip[1], 35,000 have been injured and 666 have been killed by other Palestinians partially due to the inter-Palestinian fighting after 20061. Between 2000 and 2005, 800 minors have been prosecuted in the military justice system set up by Israel in the occupied West Bank.[2] In the first five months of 2011, 533 people were left homeless because their houses were demolished, which were either built without Israeli permission in the West Bank or because of an alleged military purpose.[3]

Indirect violence, which is also called structural violence, is not carried out by a person against a person but is a consequence of social structures. It can be seen in the restrictions on movement imposed by the Israeli wall inside the West Bank, military checkpoints and the permit system, which affect the ability to travel, marry, visit family, work, study, access health and the trade of goods. This had and has severe implications, especially for the population of Gaza, in the form of supply shortages in food, fuel, medicines, etc., but also on the economic wellbeing in the West Bank. Dependency on foreign aid is very high and so are unemployment and poverty rates. Another form of indirect violence is the division of the Israeli judicial system, referring to the application of a military judicial system for Palestinians in the areas of the West Bank classified as B and C, and a parallel civil judicial system for Israeli citizens (settlers) in that same area. Due to this division a Palestinian minor (under 16 years) can be held in solitary confinement for up to 12 days with the possibility of prolonging for one week, which constitutes a breach of the UN Convention on the Rights of the Child, whereas an Israeli minor (under 18 years) cannot be arrested without the presence of a parent, lawyer or social worker[4].[5]

As the WHO puts it:

“The continuous suffering, constant fear, insecurity, feeling of neglect and lack of future brought about by the violent situation on the ground results not only in depriving Palestinian people from access to essential services, including health services but also it deeply affects their psychological well-being, particularly in the case of children. The above constitutes a deprivation of basic rights with an impact on the health status of the population.”[6]

Notwithstanding the severe effects of violence, the population created ways of coping with it. This is demonstrated by both, the high level of social capital, as in social cohesion through a strong sense of family, community, national identity, purpose and unity, and the great share of non-governmental providers of primary mental health care and psychosocial services. The communities established those NGO services in order to fill the gaps during the Jordanian and Egyptian rule until 1967, which generally increased health services but could not meet the demand of the rural population, and thereafter to respond to the neglect of the Israeli military administration on health care provision in the occupied areas until the establishment of the Palestinian Authority in 1994.[7]

PTSD in Palestine

Talking about the actual prevalence of PTSD, numbers differ widely: IRIN (Humanitarian news and analysis service by the UN Office for the Coordination of Humanitarian Affairs) released a report in July 2011 stating that according to Médecins Sans Frontières (MSF), working in Gaza and Nablus, and the Palestinian Treatment and Rehabilitation Center for Victims of Torture (TRC), operating in West Bank, the number of PTSD and anxiety disorders related to experiences of violence increased especially in children. MSF reports that half of their patients in Gaza and one-fifth in Nablus under the age of 15 years were treated for PTSD.[8]

The Birzeit University Institute for Community and Public Health (2004) also found a strong correlation between adolescents being highly exposed to violence and complaints about health problems and symptoms of psychological distress.[9] Nevertheless, the researchers are hesitant to label it as PTSD for several reasons, which are outlined later in this paper.

Madianos, Sahan and Koukia (2011) found that 45.2% of the Palestinian population in the West Bank aged from 20-65 meet diagnostic criteria of PTSD.[10] Khamis (2008) found approximately 76.5% of Palestinian youth from 12-18 who have been injured during the second intifada suffering from PTSD. Also, both studies report that PTSD often coincides with anxiety disorders and depression.[11]

Medicos del Mundo (MDM) official Boris Aristin in an interview reports that the MDM practitioners in the field only treat approximately three percent of their patients for PTSD out of the total population affected. Further on he says that it is less the direct impact of violence causing disorders but the overall context provoking diseases: “staying in this stand-by status for so many decades provoked depressions and a lack of initiative. The huge insecurity in general can develop in any kind of mental health problem like depression and loss of aims”.

The above mentioned study of the Birzeit University Institute of Community and Public Health similarly emphasizes that Palestinian youth perceive violence as an inextricable part of their daily lives.11 The threshold for being overwhelmed by it might just be higher; one is more prepared for such experiences, because they are part of their lives as Palestinians for generations. At the same time, constantly being exposed to humiliation, fear, desperation, frustration and anger might also increase general vulnerability. Depression and sadness as an answer to this constant exposure can simply be seen as a very normal reaction to a very abnormal situation, the occupation. As Giacaman et al put it: ”Feelings can fluctuate, young people are not always permanently mired in symptoms that incapacitate their ability to function on a day to day basis”[12]

Here it becomes evident how the usage of the PTSD discourse for describing the Palestinian case is problematic. Despite the fact that this discourse aims at raising awareness about the Palestinians’ suffering under decades of occupation, it also implies the danger of picturing the population as benumbed victims or mad people that need to and can be cured, which at the same time distracts from the actual political root causes of the agony. Thus, the discourse used to aim at empowerment contains the risk of disempowerment.

History of PTSD

Historically, the discourse on trauma has always been two-folded. Just as the topic concerned, the theory around it has not only developed within scientific schemes, but also according to societal conflicts. On the one hand, there is the scientific clinical psychological discourse on traumatisation and on the other hand this discussion has always been embedded in a given political situation and the moral contestations within a society on who should be recognized as a victim. As the German psychologist David Becker puts it: “We can never discuss trauma without making some kind of judgements of who is the victim and who deserves to be viewed as traumatized.”[13]

PTSD, as a psychological disorder, only entered the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. The DSM and the World Health Organisations’ ICD are the manuals guiding health professionals on how to diagnose and intervene, and insurance companies on how and what to compensate. The recognition of PTSD in these important handbooks was made possible through the very active Vietnam veteran movement in the USA that fought for the state to take responsibility for their suffering. Thus also the symptoms classifying PTSD listed in these manuals were related to the symptoms of Vietnam veterans. But traumatisation did not appear for the first time with them. There was a common notion found in Western societies that was sceptical about victims of traumatisation. Be it through working accidents or the so-called shellshock during the First World War, those claiming to be traumatized were questioned if they were true victims or rather dissemblers aiming at insurance fraught. This perception of victimhood only changed after 1945 with the holocaust survivors, who were recognized as not having chosen their suffering but being forced to become witnesses to horrendous crimes.

Due to the DSM-IV and ICD-10 definition of PTSD, the disorder is seen to be caused by a multitude of traumatic experiences of which war-related violence is only one. Sexual abuse, natural disasters and the diagnosis of a severe physical illness can be causes of PTSD as long as they meet the DSM- IV definition of being “confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others“.[14] So, in the same time having the possibility to empower victims by recognizing them as such through the acknowledgment of their suffering as a trauma, it also makes everyone suffering from extreme experiences the same. Every individual who shows a certain set of symptoms is categorised as having PTSD regardless of different contexts that triggered it. The soldier who killed becomes recognized as a victim just as the civilian who had to observe it. This might imply that everything is also curable in the same way. It only needs the right medication and then the symptoms will vanish. PTSD delivers the image of trauma being something easy to understand and address.

At this point, the question imposes itself, to what extent it makes sense to talk about an illness that is produced by a certain social context without discussing these underlying social and political forces that led to traumatisation. Trauma through violent conflict always also has a social or collective dimension because the social relations in which it happens are determined by given power structures. Man-made traumatisation destroys the basic sense of trust in the social structures that failed to prevent the violence from happening. Recognizing a victim as a victim might thus lead to demands of social justice whereas the recognition of victims as ill people rather demands medical help. Ignoring these differences results in pathologising people instead of the circumstances that lead to it.

Furthermore it is unclear if the effect of traumatisation solely occurs on an individual level. In terms of conflict, people become victims of violence often related to their belonging to a certain group, which thus also affects the glue keeping a collective together, their common identity and narrative. It can enhance social cohesion as a strategy to cope with the experienced, by, as McFarlane and Van der Kolk put it, “taming the terror together”[15]. According to Judith Herman the basic feelings caused by traumatisation are the experience of absolute helplessness in the moment of traumatisation, the following mistrust and feeling of isolation.[16] Thus to deal with traumatisation, the person concerned needs to regain a sense of agency, a feeling of self-efficacy in a social environment, which acknowledges its suffering and provides support.

The way a collective deals with its experiences of violence and humiliation, which meanings they add to it and how they anchor it in their collective history and memory will be future grounds for legitimising politics.

PTSD is diagnosed as a post-traumatic stress disorder, which lets one doubt its relevance in situations of ongoing violence. In the case of Palestine, violence has been ongoing for more than 60 years, affecting several generations. Traumatisation in this context is rarely a one-time experience but should rather be seen as traumatising sequences, as Hans Keilson suggested. He considers traumatisation rather as a process that changes within the changing social environment. The way society reacts to the bereaved people, how they receive them and deal with them, plays an important role in their actual traumatisation.[17] Traumatisation can for example stay latent for a long time and only become manifest because of a hostile social environment long after the actual experience. Hence trauma is not a wound obtained by a one-time injury, but changes the concerned person’s relation to his or her social environment and how he or she identifies with it. It cannot be “healed”, as in a hostile foreign object that can be cut out, it can only be worked through and thus become integrated into a person’s self. But in order to achieve this, the affected person needs a sense of security. Trauma keeps her or him alert to always be prepared for a renewed similar experience. As long as the affected person cannot truly believe he or she can let this shield down, it is hard to work through.

Another aspect criticised in the discourse on PTSD is the intercultural relevance and validity of the PTSD diagnosis and intervention, in other words, does pain express itself the same way in different cultures? How do people seek help and which healing procedures are valid? Going to a psychologist, admitting a mental health problem is linked to social stigmata in many cultures.[18]

A comprehensive approach to trauma­tisation through man-made disasters should see trauma both through a clinical and a societal perspective. Offering psychological release to symptoms in a cultural sensitive manner but in the same time regarding the context in which it happened and the derived meaning for the individual and community. A notion of trauma trying to achieve this is the term psychosocial trauma used by Ignacio Martín-Baró. Psychosocial trauma develops dialectically between the individual and the society, it is socially produced, and “chronic when the factors that bring it about remain intact”[19]. “Immanent is a complete collapse of a person due to a discrepancy between threatening socio-political structures and individual coping possibilities, leading to total helplessness.”²⁰ The specific historical, political, social and cultural context in which Trauma occurs is key to its development, understanding and therapy.

Mental health and psychosocial services in Palestine

Psychosocial support and mental health care are two different but often overlapping forms of services, which can be seen as complementary. Psychosocial support is community based, aiming at the interaction of social network and individual, fostering the resilience of both. Psychosocial support can be carried out by various services like school counsellors or social workers in youth centres. Psychosocial services are provided by professional staff such as psychologists and social workers or specially trained teachers and community members.[20] [21] Psychosocial support is a means of prevention as well as intervention. Nevertheless, for severe psychological disorders specialised mental health care is needed. Ideally, psychosocial support and mental health care are being coordinated.

There are four major mental health care providers in Palestine: the Palestinian Authority’s Ministry of Health (MoH), which was established in 1994 after the Oslo accords to administer the occupied territories, the United Nation Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), local and international NGOs, and the private sector.

The 2006 WHO and the MoH Aims Report on the mental health care system in West Bank and Gaza showed that out of 731 primary health care centres 56.6%[22] are operated by the MoH, followed by 36.2%²² provided by NGOs and 7.3%²¹ by UNRWA. Primary health care refers to health care on a local level as first point of consultation, for example clinics.

Secondary Mental Health Care, as in specialised psychiatric services, is provided only by the MoH in two hospitals in the West Bank with 280 beds and 39 beds in Gaza.²²

Mental health care does not seem to be a high priority for the MoH since only two percent of the general expenditure on health care is dedicated to mental health and the biggest share of these 2% is spent on the two psychiatric clinics (73%).²²

There is a shortage in qualified staff. For 3,600,000 Palestinians there are only 34 psychiatrists and 36 psychologists, some of which only hold a bachelor’s degree. Re-training is not obligatory and thus rarely carried out.²²

Those facts give a clear impression of the marginalisation of mental health concerns in Palestine.

Reasons for this can be found in a strong stigmatization of mental disorders in general and some forms of domestic or community violence that have been socially accepted for generations.[23] Besides, the MoH inherited a sector only weakly institutionalised by the Israeli military administration and is still confronted with the difficulties imposed by the ongoing occupation. The PA is hardly able to create revenues on its own, but depends on the taxes collected by the Israeli military administration and the payments of the international donors, which are volatile according to their agendas. The lack of control over external and internal borders, water and land limit the accessibility of health care institutions especially in rural areas and constrict the control over goods such as medications, which only recently created a severe lack of medicines in Gaza.

The WHO’s Eastern Mediterranean Regional Health Systems Observatory reported for 2002 a share of 48% on external funding of PA health care expenditure.[24] More recent data could not be found, but the WHO reported in 2006 that donor contribution continues to be an important source of support to the MoH budget.[25] This very high contribution of official development assistance (ODA) to the MoH Budget obviously raises concerns about its long-term stability. This will become especially relevant for the PA bid for the recognition of a Palestinian state in front of the UN which is opposed e.g. by one of the biggest ODA provider to the MoH, the US[26].

At the same time, since the Paris Declaration on Aid Effectiveness in 2005, international donors agreed on spending a bigger share of their ODA on general budget support to ODA recipients in order to increase their “ownership”. However, in Palestine the question remains of what happens to health care services when aid gets cut back as it was e.g. the case in 2006, after Hamas won the national elections. If this would happen again the NGO and private services would have to take over once more to supply the demands of the population. So, favouring direct budget support over program and project support is a rather optimistic approach, having in mind that the PA is an institution that will one day become a recognised state. On the other hand, favouring NGOs and the private sector as health care deliverers implies the danger of creating parallel structures that could weaken possible state-like institutions or the creation of state structures. Besides, non-governmental service delivery needs to be well coordinated in order to be effective and reliable and also has the problem to secure long term funding.

Apart from the fact that mental health in general is a field which tends to be neglected, or as an MDM official puts it: “mental health is always rather playing in the second league than in the champions league, this is also happening in Spain and Germany and wherever. It is a general context.”

Additionally it tends to be marginalised as part of donor policies, because the sector is not well defined and thus it is difficult to set indicators and prove the impact of mental health care.

Psychosocial support projects are also carried out by PA ministries, the UNRWA, NGOs and the private sector. The largest psychosocial program is the introduction of school counsellors provided by the Ministry of Education and the UNRWA functioning both in terms of prevention and early recognition. The school counsellors are reported to be well received by the students.[27] Also they are well positioned to interact with the students’ families and communities. Furthermore there is a range of NGOs targeting specific segments of society such as women, girls, youth, children and disabled.

How to deal with traumatisation despite ongoing violence?

Strengthening and building up both the public mental health care services and the non-governmental and governmental psychosocial programs are important in order to increase resilience. Resilience is a term derived from physics and mathematics and originally means the capacity of a material or system to return to equilibrium after a displacement. “A resilient material, for example, bends and bounces back, rather than breaks, when stressed.”[28] Community resilience refers to the ability of a community to function and adapt effectively in the aftermath of external shocks.²⁸ This term seems to be of particular importance with regard to the Palestinian cause as long as there is no end of occupation in sight.

According to Norris et al “to build collective resilience, communities must reduce risk and resource inequities, engage local people in mitigation, create organizational linkages, boost and protect social supports, and plan for not having a plan, which requires flexibility, decision-making skills, and trusted sources of information that function in the face of unknowns.“²⁸

Supporting and strengthening both public mental health services, with an increased focus on primary health care, and the non-governmental and governmental psychosocial programs could strengthen community resilience because the better a network of established resources is organised, the less detrimental it is if one entity breaks away. Diversification of mental health care and psychosocial support programs increases stability and independency. Non-governmental programmes and projects should not be neglected in order to reduce the risk imposed by possible political events leading to a cut back in aid to PA implemented services. In addition, drawing on the already existing resources, coordinating and combining them with new resources is more effective and efficient than only focusing on the establishment of new ones. Nevertheless, the main object should be a state-delivered public health system.

Psychosocial programs and primary health care are positioned closer in the immediate communities, which has the advantage that they can bypass the fears of stigmatization attached to mental health issues because they operate within the socially accepted norms in the particular community and are thus culturally sensitive. Besides, they can offer prevention, recognise problems at an early stage and transfer patients to more specialised services if necessary.

Furthermore, psychosocial programs can aim at more than only the individual level. Ideally they create community cohesion through working together with the community and thus link the experience of the affected individual to its wider group. They can create spaces in which affected individuals themselves can engage in community work, which gives them a feeling of purpose and self-efficacy to counter the experienced helplessness and isolation. This seems of particular importance in order to oppose the effects of the occupation especially on youth.

“The appropriate services must not only offer them the resource and tools to adapt positively to current realities, but also the potential to exercise their right to participation and agency in a constructive way”. [29]

These programs should not only focus on the most severe cases showing extreme psychological symptoms, but address the effects of the occupation on affected people more generally. They can provide possibilities for sharing the experiences and to determine what should be the scope and aim of those programs according to actual needs, which is important as these vary across communities.

Nevertheless, in order to work effectively these often very small-scale psychosocial programs should be long-term focused and undergo a centralised coordination process in order to ensure that services cover not only some preferential areas and marginalise others. This coordination process would need to include all programs and projects working in that area, from international to local, and avoid pitfalls of typical exclusionary mechanisms in choices of language, locations for meetings, etc.

Concerning the international community it would be desirable to ensure ODA flows at a constant and predictable level, to both the MoH and NGOs, to ensure that neither general mental health care, nor psychosocial projects and programs are marginalised. However, besides the importance of mitigating symptoms of direct and indirect violence, it is crucial to step up and address the root causes.

Talking about severe victimisation in the context of neglecting almost any means of self-empowerment and much needed experience of agency – like in the cases of rejecting the Boycott, Divestment, and Sanctions campaign (BDS) as a non-violent means for resisting the occupation, the Israeli boycott law, the rejection of the bid for statehood in front of the UN by influential EU member states and the US – can be seen as disempowering. It often appears that it might just be easier to picture Palestinians as passive, helpless victims that can be helped by medical prescriptions for symptom relief, rather than to actually allowing them to foster social and political change themselves.