When he founded the Gaza Community Mental Health Programme (GCMHP) in 1990, Dr. Eyad El Sarraj transformed the way mental health and wellness were treated and discussed in Gaza. A self-described “pathological optimist,” he strove to create a community of unified resistance whose self-healing process was inextricably linked with the struggle for a just peace. GCMHP has been central to this process in Gaza after each of the three large-scale Israeli assaults on Gaza (in 2008, 2012, and 2014), helping the community to work through both collective and individual trauma.
The work comes with many challenges. In addition to dealing with the resource shortage generated by the Israeli blockade, mental health workers must cope with their own trauma while aiding others. The current director of the GCMHP, Dr. Yasser Abu Jamei, knows the problem firsthand: during Israel’s Operation Protective Edge (OPE), the fifty-day war on Gaza in the summer of 2014, an airstrike killed twenty-eight members of his extended family, including nineteen children, as they broke their Ramadan fast. It was the largest loss of life within a single family at that point in the war. Abu Jamei continued his work at GCMHP, providing mental health support to the community both during and after the onslaught.
Over twenty-one hundred Palestinians, five hundred of them children, were killed during OPE and another eleven thousand injured. The structural damage was similarly catastrophic, leaving over one hundred thousand Gazans homeless. Although Israel has loosened restrictions slightly on the amount of reconstruction material allowed into the territory, one year on from the end of OPE, the United Nations Conference on Trade and Development (UNCTAD) released a report warning that Gaza will be unlivable by 2020 if current economic and humanitarian trends continue. [*] (For a more in-depth discussion of OPE, see JPS 44 , a special issue published after the cease-fire was reached on 26 August 2014.)
The summer 2014 assault has had lasting consequences for Gaza’s residents. An examination of their situation reveals that long after the cease-fire, the psychological wounds sustained during consecutive assaults continue to disrupt everyday life. This is especially true among children. The United Nations Children’s Emergency Fund (UNICEF) estimates that over one-third of Gaza’s children require direct and specialized psychosocial support as a result of OPE and earlier assaults. Continuous feelings of fear and anxiety afflict many Gazans, and the ubiquity of ruined buildings and devastated neighborhoods serves as a constant reminder of violence and loss.
GCMHP offers an array of programs to meet these challenges, including capacity-building programs and trainings, community education, scientific research, and human rights advocacy and mobilization. The organization provides services free of charge at clinics, community centers, and by phone via a twenty-four-hour hotline. Through its outreach to families, schools, medical professionals, and civil servants, the number of self- and family referrals has greatly increased. The organization estimates that since its founding, it has served more than twenty thousand Gazans using its hallmark collaborative approach to care that empowers families and communities to support each other through the healing process and regain a sense of security.
In October 2015, JPS assistant editor Brittany Dawson and Zeina Azzam, executive director of the Palestine Center, sat down with Abu Jamei in Washington to discuss his work. In the interview that follows, Abu Jamei talks about manifestations of trauma, methods of treatment, and how mental health professionals care for themselves and each other in an environment with little break from sustained conflict. Ultimately, his is a message of hope for the power of resilience, recovery, and perseverance in Gaza.
To start, how do adults and children in Gaza, who are suffering from trauma as a result of the war and the blockade, manifest this trauma? And what are the more complex and long-term ramifications?
Although this is a single question, to answer it needs a lot of discussion. Actually, it’s good that you mention children and adults separately. In the three GCMHP centers across the Gaza Strip, in the last year or so—from August 2014 until July of this year—almost 35 percent of our adult clients have exhibited a major depressive disorder and another 25 percent have post-traumatic stress disorder (PTSD). We believe that the last offensive had the greatest impact not only because of the level of destruction but because of the losses associated with that destruction: loss of people, loss of houses, the sheer scale of the destruction, as well as the desperate lack of employment opportunities. That’s why we think that the adults who came in to our clinics exhibited more depression than trauma.
With children, the opposite is true. Up to now, some 45 percent of children coming into our community centers have PTSD and another 10 percent suffer from bed-wetting episodes. In the last year, ever since the last offensive, we have been seeing three or four major issues in children: bedwetting; poor school performance; problems with discipline; and, lastly, night terrors, which are episodes of uncontrolled screaming in the middle of the night when the child continues to scream while asleep and remembers nothing after being woken up.
What age groups are we talking about?
When I speak about bed-wetting, it’s mostly in the nine to ten age range, sometimes even as old as twelve and thirteen; for night terrors, it’s almost the same age group but it starts even earlier than that, and includes children as young as three to seven years old.
How do affected individuals go about seeking treatment? Are they most often referred by family members or by social workers?
This is a good question. In our society, mental health problems are often viewed as a stigma. That’s why ever since GCMHP’s establishment, we have been investing a lot of energy and resources into community awareness and public education, especially with radio and TV programs. The good news is that although we started with zero percent referrals—I mean self-referrals—and every case we saw came via medical referral, by 2014, some 70 percent of clients were self- or family referred. While this is a major improvement, stigma around seeking mental health treatment definitely remains and that’s why now in addition to our clinics we have a toll-free line where people can call and check in without showing up. This gives them a chance to think about, or give consideration to the possibility of coming in to one of our centers. We try and reassure them that they are in good hands, we emphasize that their confidentiality is guaranteed, and discuss with them whether or not they could benefit from our services. Women constitute 65 percent of those who call in, and this is evidence of how important it is for us to keep this toll-free line active because there is clearly a gender issue here. Women are at greater risk [for depression] and it’s possible that for women who feel more embarrassed about seeking help, the hotline is a good alternative to going to one of the community centers.
Can you tell us a little bit about the educational programs on mental health services? Are they in schools? Are they in the community?
We have a number of capacity-building programs that we offer. We offer training for professionals who work in the Gaza Strip (teachers, medical personnel, and so forth). In some instances, we deliver the training programs ourselves and in others we invite international experts from Europe and the United States to run training in Gaza. That’s one part of it, but the other part of it is to talk to the community—to relatives, to fathers, to mothers, and the general population. We explain that if a child is wetting his bed, he might have a psychological problem. We of course first have to exclude the possibility of an organic disorder, but if there is none then they might need to come to the community center.
We also work with schools because it is very important to intervene with children in that setting, where we can also get additional support from the school counselors. We work even with kindergartens, and that is also going very well. Working in schools also helps us reach the community: when you have activities in the schools you have more access to the community and it becomes less stigmatizing for people to address their children’s needs and come to our community centers.
How do mental health workers cope with the challenging situation? Do they have access to the same types of resources as your own clients?
You know, the last offensive went on for some fifty-one days and our staff, about seventy people altogether, were experiencing the same feelings as everyone else living in Gaza: the lack of security, that there was no safe place to be, and that you could get killed at any moment. This is one of the most serious problems we have to deal with but over the course of the decades since GCMHP was established in 1990, we have come to understand the importance not only of supervision, but of care for caregivers, of being there for each other, and talking to each other: I call it emptying the cup each time it gets full; that is very important. I would like to add too that we (the caregivers) also get support one way or the other from many of our colleagues in the international and scientific community . . . they come to Gaza and provide our staff with continuing education/supervision but also care for the caregivers. This is crucial to preventing secondary traumatization. In the case of caregivers, traumatization is often both primary and secondary and, luckily, so far we have been doing well. You know, it’s very important for us when we see successes: treating a child, or dealing with a family, training the parents to deal with their children, how to provide them with security and feelings of safety in spite of everything, and then seeing the child’s grades improving at school and no longer wetting his or her bed. Successes add a very nice touch to our work and just keep us motivated and working.
Could you just explain for our readers what are primary and secondary traumatization?
When you yourself have been exposed to a traumatic event, for example to the possibility of death or physical injury or a life-threatening situation and start suffering, this is primary trauma. Secondary trauma is the trauma of those who intervene with traumatized individuals, and this is not restricted to mental health practitioners but extends to primary healthcare, emergency personnel, as well as police and civil defense workers, basically anyone who works directly with the traumatized and is exposed to their suffering and to hearing their stories. That’s why we call it secondary because while you yourself were not directly exposed to the trauma, you are indirectly exposed by virtue of being the interlocutor of the person who suffered the traumatic event.
So you become traumatized yourself because you are hearing this incredible trauma. So you almost personalize it or you empathize or maybe feel this intense identification . . .
You cannot work with children unless you have empathy. Empathy is part of the therapeutic relationship and process. However, you need to make sure that as you’re working with the child, or client, that your feelings are set aside, that’s why you need to always make sure to empty that cup, because when it gets filled then you are really in trouble and then at that moment, you yourself will need help.
Can you please talk a little bit more about the effects trauma has had on family units, especially in terms of social cohesion and stress on relationships?
Social cohesion is one of the most important moderating factors that help people survive during very difficult times. But one needs to remember that even if you have strong social cohesion in Gaza it doesn’t mean people can continue to be resilient forever. Over the years people have been depleted of their resources—economic, financial, farming land, property, their very homes. It’s like when you build your own house, you might have saved for thirty years before you can build it. And suddenly it’s all gone . . . in one second that house is not there. Many people are running out of resources, and that’s why we had more cases coming to our community centers immediately after 2014—to this very day. So yes, there is resilience and we have many tempering factors such as social cohesion but the problem is that over time people’s resources are being completely depleted.
Going back to the idea of safety, can you please talk a little about the meaning of safety in a context like Gaza’s? How do you go about treating post-traumatic stress in a situation where there’s no sustained break from military attacks and blockade?
You know, according to different media sources, including Israeli ones, more than fifty thousand missiles fell on Gaza during the last war—that is one thousand shells per day in that tiny geographical area. What this means is that every single person could at any moment witness in some way or the other a war-related event: falling shell or projectile, or smoke in the sky, or whatever other forms of strike, including aerial and naval bombardment. This meant that the residents of Gaza had a fifty-day continuous fear of death and the sense that there was no secure place and no safety.
Today, although there is mostly no shelling taking place, there continue to be cues or triggers that remind people of the traumatic events—for example you see and hear drones in the sky, you hear rumors of escalating tension, you hear from the media that Gaza could be targeted again, and there are many other things as well. Even though it has been almost fourteen months since the cease-fire, there are places in the Gaza Strip that are still full of rubble and destruction. Children going to school, or on their way to kindergarten, pass by those mountains of rubble, meaning that trauma is triggered, the reminders are always there, and this makes our work doubly difficult and it lessens people’s ability to regain a feeling of security and safety. This is one of the challenges we face in our work.
How we address this? Children are not capable of talking about their experiences, they cannot say, “I’m anxious,” especially the very young. So what we do is find other means of communicating with them, helping them to accept themselves. Two examples of the types of approaches we use to achieve this are play therapy and drawing or art therapy. If you get a child into a room full of toys, and ask her to pick a toy, she might pick a family of dolls and start speaking about the problems between her father and mother or that she feels jealous of her brother. In this way, you just can start feeling your way into what is upsetting her. Another child might pick soldiers or airplanes, or an ambulance, and then he might start to tell the story about how he feels frightened, about his feelings of insecurity. And in that way, you come to understand his difficulty and what is ailing that child and you start communicating with the parents and talking to them. Those children come to our clinics for maybe two sessions per week; they’re with us for a maximum of two hours, but their parents are with them all day. So you discuss with the parents what they might do with the child for instance at bedtime, telling him or her a story, staying in the room for a little bit, calming the child, and making him or her feel that everything is safe, and then slowly letting the child drift off to sleep. Sometimes we organize activities for traumatized children; we take them on picnics and have recreational days where they can just have fun . . . because in addition to the rubble everywhere, and all the difficulties they face, they need to add colorful experiences to their memories. And that really works well.
Speaking of parents, it seems that one of the more traumatic feelings that children could have is that their own parents cannot protect them. It seems like a very profound expectation children have that their parents can protect them, but in a state of war even their parents can’t keep them safe. This must be a very important piece of what you work on.
Let’s remember that even as long ago as the first intifada (1987–93), the Israeli forces, the soldiers used to come in to the houses and sometimes humiliate and insult the parents in front of their children. That has many implications: first of all that the parent is not the authority at home anymore; that discipline is no longer needed; that the best way to defend yourself is to be the powerful one; and that obedience is not the best way to do things.
And now, years later there are other ways that the occupation is brutal and aggressive, and again parents find themselves in many ways incapable of providing their children with a safe place. From a psychological point of view, when children exhibit a lack of discipline, defiance, and growing aggressivity, it is a reflection of the very brutal environment and society that they live in. Let’s not forget that the Gaza Strip is still under occupation. All the entrances and exits to Gaza, the crossings, are controlled by the Israelis, and they control everything that comes into Gaza, be it food, fuel, or any other necessity . . . we are just like a big open-air prison and we cannot expect from people living in such conditions just to behave well and be good, it doesn’t work like that.
Have you and others at GCMHP had the opportunity to learn from mental health workers who have worked in other war zones and are there any sorts of models that you use for treating collective trauma?
Various people who do trauma-related work in different areas of the world visit the center, but ours is a rather unique situation. In other areas of the world, people are living in a generally peaceful environment and a calm situation when suddenly they experience a traumatic event like a tsunami (or other natural disasters such as an earthquake or hurricane) or a war, and then the whole nation and countries in the area start disaster and crisis intervention and try to help. But in Gaza it is a lot different. First, there is no “pre-” because 2014 was preceded by 2012, was preceded by 2008, was preceded by the second intifada and then the first intifada and then the whole occupation, you know. So there is no “pre-” situation.
And when it comes to the “post-,” your readers know that reconstruction materials are still in short supply and it took almost one year (June 2015) to announce the rebuilding of the first one thousand houses since the end of the last offensive. And there are eighteen thousand houses that need to be rebuilt. So the “post-” is not a real “post-” because there is an ongoing situation that cannot be described as having attained the status of “calm.”
I’ll give you a very interesting example: you know part of the 2014 war took place during Ramadan, and the Ramadan that just passed, which was three months ago, some of the children were asking their moms the following very simple question: “So Ramadan is coming—are we going to have another war?” Imagine that something as positive as anticipating Ramadan, with its unique rhythms of iftar at dusk and suhur at dawn, and all the other positive associations with that month . . . but on the children’s minds was whether it would bring another war or not. It’s not easy but what is needed is that we do our best all the time, to constantly find the means to strengthen hope in people’s hearts and minds, and to nourish it one way or the other.
Do you have a final word to leave us with, Dr. Abu Jamei?
I would like to say that at GCMHP we try to find hope in people’s life, and we try to build on that. And I’d like to think that we often succeed and that we succeed in several ways. So if we in Gaza are not losing hope, I tell colleagues and friends as well as Palestinians in the United States, “We haven’t lost hope and you too should not lose hope. Constantly try and think of creative means of helping people in Gaza. Despite the distance, we are not far away.” Palestinian Well-Being: Suffering, Resilience, and Political Liberation
[*] United Nations Conference on Trade and Development, Report on UNCTAD Assistance to the Palestinian People: Developments in the Economy of the Occupied Palestinian Territory (Geneva: United Nations, 6 July 2015).