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An Epidemic Without a Name

Post-Traumatic Stress Disorder (PTSD) is a term that was coined in 1980 by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders III.  Recognition of the disorder came about following the Vietnam war, when 700,000 US veterans (nearly a quarter of the army) returned home with what was labeled “Vietnam Syndrome,” or psychological damage. The ensemble of their symptoms would later be called “Post-Traumatic Stress Disorder.” This condition was determined with regard to individuals who suffered past (not present) trauma, hence the word “post.” It was identified within a society which could not begin to imagine incessant suffering or the effects of constant occupation–the grim reality facing Palestine. With a stagnating economic situation, persistent violence, and incursions by Israeli forces, Palestine suffers from a severe mental health epidemic.

According to a 2007 study in the Gaza strip, nearly 60 percent of Palestinian adults suffer from PTSD, while children suffer at an alarming rate of 70 percent.  Even in the more prosperous West Bank, 34 percent of children suffer from PTSD.  In comparison, a mere 8 percent of American adults, and 12.5 percent of American veterans of the Iraq and Afghanistan wars have PTSD.  Similarly, only 4 percent of American children under 18 are exposed to traumas that could lead to PTSD, and of that group PTSD only  7 percent of girls and 2 percent of boys are diagnosed with the illness. However, many of the psychological conditions that Palestinians face are mislabeled as PTSD; according to Palestinian psychologist and chair of the mental health department at the Palestinian Ministry of Health, Samah Jabr, the mental health problems she witnesses, do not, in fact, resemble PTSD. Instead, “the effect is more profound. It changes the personality, it changes the belief system.”

Palestinians without a doubt suffer from a variety of mental health issues caused by the occupation. Many do in fact suffer from PTSD. However, using PTSD as a blanket term for mental health disorders that do not resemble it diminishes the severe, and ongoing nature of Palestinian trauma, and imposes ill-fitting Western mental health standards on communities that cannot be defined in such terms. The stress disorders afflicting Palestinians need updated terminology and case definitions to ensure effective patient care.

Dr. Gillian Straker offers a different term: continuous traumatic stress (CTS). She developed this term during the South African apartheid (a situation in many ways analogous to that of Palestine), when she found that PTSD treatments on those who suffered constant traumatic stress proved ineffective. For children and adolescents, Straker argues that the term Developmental Trauma Disorder (DTD) be used. Unlike PTSD which often develops after a single event, CTS and DTD are the product of repeated or ongoing trauma.  Symptoms of DTD include “behavioral problems, poor impulse control, pathological self-soothing, suicidal thoughts and sleep problems.” Palestinian children display similar symptoms , with 28.5 percent in the West Bank and 25.9 percent in Gaza having considered suicide.  An alarming number of households across the West Bank (such as 93 percent of households in Ramallah, 91 percent in Tulkarem, 89 percent in Jenin) reported having members who experienced “psychological distress, with high reports of … hopelessness… depression, [and] sleeplessness” which resemble the symptoms of CTS. Additionally, unlike PTSD, CTS often incites “agoraphobia” (fear of crowded spaces), “high levels of substance abuse,” and emotional “dysregulation.” These same symptoms are also seen among Palestinians. Many Palestinian children suffer from agoraphobia, Gaza is currently experiencing an opioid crisis, and many Palestinians who have experienced trauma suffer from “uncontrollable fear” and unexplained “crying,” symptoms of affective dysregulation. Observationally, many Palestinians exhibit symptoms similar to those of Continuous Traumatic Stress.

Mental health issues in Palestine are only exacerbated by the deficient Palestinian mental health care system. The mental health system is underfunded, doctors and treatment centers are scarce, and many of the psycho-social institutions are based in Western perceptions of mental health.

The mental health infrastructure in Palestine is is extremely insufficient. Currently only 2.5 percent of health funding in the West Bank goes to mental health care.  There are only “two mental health hospitals” in the West Bank, totaling 319 beds, and both lack a ward for children or adolescents. In all of Palestine, there are a mere 32 psychiatrists and 36 psychologists, according to a World Health Organization (WHO) report. While most treatment is offered through clinics or hospitals run through the Palestinian Ministry of Health, several non-governmental agencies also play a role in treatment, such as UNRWA, Doctors Without Borders, and Palestinian Red Crescent. However, there is a “lack of effective coordination” between these groups, causing a scarcity of mental health services.

According to Institute for Health Metrics and Evaluation Global Burden of Disease (GBD) report, approximately 4.5 percent of Palestinians suffer from anxiety disorders. This stands in stark contrast to the aforementioned statistic stating that 60 percent of Palestinian adults suffer from PTSD. This is due to the fact that the GBD relies on passive reporting, which is impaired by the fact that Palestine has extremely limited psychiatric care, whereas the latter is drawn from actively diagnosed cases.  Moreover, a 2002 Norwegian study of Gaza found that general practitioners only recognized serious mental health problems in “12 percent of cases” leaving “88 percent of mental illness[es] undetected.” This indicates that the current Palestinian mental health system is severely lacking, and misses the vast majority of cases of trauma survivors.

One of most ambitious endeavors to treat mental health problems in Palestine has been the placement of psychological counselors by the UNRWA in primary and secondary schools.  However, many of the counselors and other “psychosocial providers” are “based on projects funded and formulated from abroad,” which often means that the criteria and treatment for mental health issues are based on Western metrics, such as those for PTSD. Furthermore, these counselors often “feel a lack of clarity about their role” and their training typically centers on “individual therapy and emotional ventilation.”  The practice of emotional ventilation to treat mental health issues is very Western however, and thus “unfamiliar” to Palestinians. Furthermore, there is a cultural stigma attached to reaching out to a counselor, and thus many students prefer to “go to a teacher.”  According to a 2004 study by Rita Giacaman, psychologist and professor at Birzeit University in the West Bank, many counselors who face obstacles in treating pupils may be experiencing difficulties due to the fact that staff training is potentially “culturally [in]appropriate.

Continuous traumatic stress and developmental stress disorder are relatively new terms, and have not been unanimously added to the official psychological lexicon. It was added to the most recent edition of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems, however it remains excluded from the American Psychiatric Association’s (APA)’s  Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Despite CTS’s inclusion by WHO, Palestinian suffering remains categorized as “PTSD” by the organization.  Similarly, the UN Office of High Commissioner for Human Rights also only acknowledges PTSD in Palestinian citizens.

This inaccurate terminology will allow patient care to remain as inadequate as it is now. Many mental health workers within Palestine have been taught outside of Palestine. 27 percent of counselors in Palestinian schools have been educated in foreign universities, according to Giacaman. The medical director of Bethlehem Psychiatric Hospital is a Croatian woman who studied in Europe. WHO’s Mental Health Development project in Palestine includes training mental health workers abroad (in countries such as “France, Italy and the United Kingdom”). And a substantial amount of the mental health workers in Palestine, such as those from Doctors Without Borders, are not from Palestine. It is therefore likely that many mental health workers in Palestine have been trained in forms of psychology grounded in Western mental health practices, which do not account for the grave and distinct nature of continuous trauma. Palestine’s reliance on foreign medical aid means that psychiatric care of Palestinians is very much shaped by exogenous definitions and predictions of Palestinian mental health.  Thus, it is necessary to introduce CTS into psychological terminology, as the status of CTS in the global medical vocabulary therefore largely determines physicians’ understanding of anxiety disorders in Palestine. Merely using the term “PTSD” encourages treatment plans unsuited to the experiences of many Palestinians.

To end this mental health epidemic, psychologists must first acknowledge CTS. Additionally, a new metric must be devised for determining traumatic disorders. An example is the Gaza Traumatic Checklist which was used during a 2008 study regarding children and PTSD in the Gaza Strip. This indicates that researchers have come to understand the unique traumatic environment in places of constant violence, marginalization and oppression. However, this realization has yet to produce an official standard for constant traumatic stress.

Increased literacy with regard to continuous stress for counselors, therapists and psychologists is vital. Instead of relying on PTSD treatments which attempt to “detoxify imagery and arousal” connected to the previous traumatic experience, psychologists should focus on preparing patients for “future traumatization” and helping patients distinguish between “everyday stimuli” and those which could “pose a real, immediate, or substantial threat” Psychological care for victims of CTS and PTSD vary significantly. PTSD treatments typically are individual, center on exposure therapy, and desensitizing the patient from triggers. CTS therapies on the other hand, involve a more community-oriented and holistic approach: trauma healing, coping workshops and the creation safe spaces for patients.

A model that should be applied in Palestine is the “three-tiered community-based rehabilitation model” that was developed in India for victims of chronic schizophrenia. This model involves case workers that are members of the populations they serve, and local village health groups comprised of family members and key individuals in the community. This type of initiative is much superior to outpatient care, as 63 percent of patients in the group-centered approach were fully compliant to their treatment regimen after one year, compared with just 40 percent of those who received outpatient care. Similarly, Dr. Jabr calls for an “interdisciplinary” approach to mental health care: incorporating “social workers, psychologists,” teachers and “family members” into patient care. A type of program suggested for children is one created by the International Trauma Treatment Program (ITTP).  The ITTP sends mental health workers into schools to encourage students to use “the arts, creative writing, [and] dance” to build systems of support for young trauma victims.  In each intervention strategy, establishing a sense of trust in and support from the institutions, doctors, and communities making up the Palestinian mental health system is vital to their success.

The Gaza Community Mental Health Program already holds workshops similar to those that treat CTS, making implementation of such practices more practical in Gaza. Similar programs, however, need to be established in the West Bank.

PTSD and CTS do share some forms of therapy, making the implementation of CTS treatment efficient. An example is Eye Movement Desensitization and Reprocessing, a therapy in which patients recall traumatic memories while their eyes follow the hand movements of a clinician. During the treatment, patients begin to process the memory and disturbing feelings.” Ultimately, patients are able to shift their own perception of their trauma from that of a victim to that of a survivor, consequently empowering the patient. EMDR is commonly used to treat PTSD, and is helpful for CTS as well. Another treatment is  Trauma-Focused Cognitive Behavior Therapy (TF-CBT). It is a holistic therapeutic approach which incorporates more traditional “cognitive processing” therapy with familial practices, “relaxation” techniques and “affective regulation.” TF-CBT is also employed for cases of PTSD, and can be particularly remedial for victims of continuous trauma. There are currently  millions of dollars being funneled into PTSD programs in war zones globally, including Palestine. Shifting slightly from current PTSD programs to an approach that is more holistic and encompasses continuous traumatic stress, while also using existing infrastructure, will benefit the Palestinian people at a minimal financial cost

Avoiding the term Continuous Traumatic Stress prevents proper treatments to be implemented and inhibits healing of Palestinian citizens. The sole usage of PTSD in reference to Palestinian citizens is dismissive of the unfinished nature of Palestinian trauma, and only impedes the alleviation of Palestinian suffering. While Palestine’s overall health care system is insufficient, their mental health programs are severely inadequate. International recognition of Continuous Traumatic Stress and application of this term to treatments in Palestine will help to improve the quality of life of the millions of Palestinians who suffer from debilitating mental health disorders caused by the constant trauma of occupation, while limiting its strain on Palestine’s financial resources. Only once an accurate understanding of Palestinian trauma is integrated into Western mental health treatment guidelines can we effectively begin to combat the mental health crisis plaguing Palestine today.