instrumental, though not exclusively so, in shaping how the Palestinian psychosocial organizations have grown, and have set the benchmarks in the Middle East and internationally (Hanafi and Tabar 2005). Though the Psychosocial Bill was pushed by the Ministry of Health in 2009, there is little doubt as to where the best counselors go: to the generously funded NGOs. Therefore the Ministry of Health looks to them, as well as the World Health Organization in Palestine, when it wants to establish so-called best practices.
The infrastructure of psychological care in Palestine is thus remarkably different than elsewhere in the Levant or the Middle East in general. There is most certainly a space for the local sheikhs in offering assistance to the distressed, at least in the countryside and in the more conservative parts of the West Bank and Gaza. But such traditional healers arguably play a less significant role than, for example, in the contemporary Egypt that Amira Mittermaier and Paola Abenante describe in their powerful work (Mittermaier 2011, 2014; Abenante 2012). In Palestine, there is a general familiarity with Western psychology due to Palestine’s colonial past and the ways that European and American concern about the Palestinian plight has been expressed in psychosocial interventions for a traumatized population. Consequently, there is a receptivity, however minimal, to understanding the effects on the psyche that the military occupation may have had. One might go so far as to say that psychology, counseling, and psychiatry have become close to household terms due to the massive effort to raise awareness about the psychological consequences of violence. The largest effort was spearheaded by the late Palestinian psychiatrist Eyad al-Sarraj, whose Gaza Community Mental Health Program has educated and provided services to many a Gazan since the 1990s (Fischer 2007; Perdigon 2011). More than any other, Sarraj’s approach embodies Fassin’s notion of a humanitarian psychiatry, and his approach to the effects of the occupation on Palestinians has been tremendously significant in terms of how the language of trauma, like that of human rights, has become the language of Palestinian victimhood (Allen 2012).
Organizations with a psychosocial mandate thus employ an ever-growing number of the educated Palestinian middle class of health professionals. Nejmeh nonetheless pointed out that indicative of these professionals is “a lack of human resources: we don’t have psychiatrists. Instead we have people who study psychology and then they act as psychological consultants. And we have social workers who have had some training in psychology and sociological behavior.” Whereas therapists have earned BAs in psychology and education, generally from Birzeit University, specialized training is given within the NGOs. These courses are funded and negotiated by the centers’ donors. As the research coordinator of the Prisoners’ Support Center told me, “We follow the fashion. We might want a course in family therapy, but in Europe or the US, EMDR or CBT is on everybody’s lips and thus on the list of training courses that, for example, the EU want[s] to fund because it is evidence based.” The bulk of Palestinian therapists I spoke to described their therapeutic approaches as eclectic, comprehensive psychosocial programs that take into consideration the entire human being and his or her lifeworld. However, access to the treatment and services offered by the centers mentioned above are allocated according to clients’ scores on the Harvard Trauma Questionnaire and other mental-health-ranking instruments. These scores determine whether the client shows symptoms of anxiety disorder, depression, or PTSD. Hence, what seemed initially to be peripheral to the psychosocial services available to prisoners and their families—namely, trauma—proved in fact to be at the very center of such services.
The complexity of diagnostic practices dawned on me when I joined the newly educated therapist Ahmad at a school in Salfit, where he was to undertake psychosocial interventions. The visit to the school is part of the so-called outreach work, which recognizes that many clients are not able to come to the center’s offices for treatment due to financial constraints or fear of stigma. Outreach work is popul ar among psychosocial organizations, among the target group of clients, and not least among the donors. It is taken as a sign that the organizations, far from being elitist, are committed to helping beneficiaries who are most in need. At the Prisoners’ Support Center, well over half of the consultations took place through outreach work. The work is often done by the newest employees in the organization and thus often by those who have the least clinical experience. In the morning, the therapists travel to the village targeted for that day’s outreach work. Either they are driven by the center’s driver in its car or they take as-servīs (a minibus). Upon arrival at the villages or refugee camps, the therapists are dropped off at their clients’ houses. The driver then waits for two or three hours while the therapists finish their work.
Therapists often dread outreach work. It involves the hassle of a long journey, few or no breaks, and the frustration of not being able to do proper therapy. When the therapeutic space is the home, the client’s family, children, and guests frequently walk in and out of the sessions. At the end of the day, the weariness of the car full of therapists is palpable, and the ensuing hours of recovery long. Many of the therapists I spoke with doubted the efficiency of the outreach work, but donors like it. Given the pressure of being able to prove that services are effective and reach as many people as possible, the outreach teams I met were often under pressure to see as many clients as possible during their trips. Thus after a long car journey on the Palestinian by-roads, Ahmad, the driver, and I reached the school, where we went straight to the director’s office, outside of which three children were waiting. Ahmad asked one of the children to join him, and the other two had to wait. The case concerned a young boy who had witnessed his father being injured by Israeli soldiers in the street. The father had survived, but apparently the child suffered from concentration problems. Closing the door behind us, Ahmad took out his papers and went through the checklist for symptoms for around twenty minutes, during which time curious children constantly banged on the door and pushed it open with roars of laughter. The boy then left the room and Ahmad told me that he had PTSD and listed the symptoms from the DSM-IV. The examination of the two other children followed the same procedure. After the three consultations, we left the school and got into the car to go back to Ramallah.
The point here is not to expose Ahmad as a therapist who is not quite at home with the difficult work of diagnosis, but, rather, to reveal how the notion of trauma is, in practice, employed under the umbrella of psychosocial interventions. Psychosocial intervention is common, and would not raise eyebrows in the West Bank and Gaza, but it is worth underscoring that in its combination of an individual and social approach to the suffering person, it is based on a conceptualization of suffering as an individualized and biomedical trauma. Ahmad’s translation of the boy’s concentration problems into the language of trauma was a way for the therapist to know the boy’s affliction and therefore help ameliorate his distress. Trauma here serves as a useful proxy of suffering, and one that is a result of the many factors that influenced the therapists: donor pressure, the lack of clinical training, burnout, and the fact that the therapists often share the experiences of their clients.
With an eye to current and potential donors, the diagnosis of posttraumatic stress disorder is therefore important to Palestinian organizations because it allows them to document their activities with so-called evidence-based therapy, among them cognitive behavioral therapy (CBT). The effectiveness of CBT and narrative exposure therapy have been tested through randomized control trials of victims of rape, American Vietnam War veterans, victims of terror attacks, and British victims of traffic accidents (Bisson and Andrew 2009; Bisson 2008; van der Kolk and Blaustein 2005; Gersons and Olff 2005; Basoglu 2003). Hence, donors assume these methods will be effective among traumatized Palestinians, too.
The fact that Palestinians have to have experienced a traumatic event in order for their distress to be acknowledged goes beyond the issue of therapy. Consider Maryam, whose life figures in more detail in Chapters 4 and 5. She is the mother of three children, and her youngest son was only three when we first met. Maryam recounted how he caused her endless distress, to the point where she actually had to have him on a leash in his room in order to take care of her other children and household chores. Her mother-in-law scolded her, saying that his behavior showed she had failed to discipline her child appropriately. Two years later, she told me with relief
