The 21st century has brought with it an urgent requirement to
respond to the mental health needs of people, both individually and
collectively, in order to move them beyond their immediate
challenges. This is particularly true in areas of conflict. It is
our philosophy that mental health in its wider perspective includes
an inseparable bio-psychosocial link that must be emphasized in the
relationship between mental health and human rights. Our hopes for
peace, freedom, and democracy - hopes that all people and societies
share - lie in strengthening capacity-building and in a greater
involvement of people in embracing their own mental health related
issues. This entails equipping mental health professionals with
interdisciplinary skills to be able to advocate, from within,
effective and meaningful social, economic and cultural changes that
include the need for fresh perspectives about the relationship
between mental health and human rights.
The training of mental health professionals in regions where there
is a lack of respect for human rights is an important first step in
understanding and intervening in the psychologically degenerative
effects of human rights abuses and traumatic experiences. The
innovative initiative of the Diploma in Community Mental Health at
the Gaza Community Mental Health Program, which was started in
1997, is one such training project designed to train mental health
professionals in Palestine. Our mental health training is based on
linking human rights with mental health. Mental health in its wider
perspective encompasses environmental, family, and community health
factors, not just an inflexible medical perspective. The diploma is
considered a cornerstone toward the formation of an Institute of
Mental Health and Human Rights that will train mental health
professionals in the Middle East to manage and intervene against
the often cumulative effects of human rights abuses and traumatic
experiences on individuals and their societies.
The Gazan Backdrop
According to the Palestine Monitor, in the last three years from
September 2000 to October 2003, more than 2,654 Palestinians have
been killed - 493, or almost one in five, were children aged 17 or
younger. Another 47,000 have been injured. Of those, 2,500 will be
permanently disabled, some 500 children. In October 2003, Israeli
occupation forces reinvaded Rafah leaving more than eight people
dead, 114 refugee shelters destroyed, 117 buildings damaged, more
than 120 houses demolished, and 1,240 individuals homeless. This
attack on Rafah has brought the total number made homeless in Rafah
alone, since the start of the second Intifada, to 7,523. In the
whole of the Gaza Strip, 11,987 have been made homeless and the
number is rising every day.
There are now 482 Israeli military checkpoints across the West Bank
and Gaza Strip, dividing the West Bank into 300 clusters and the
Gaza Strip into four areas. These checkpoints have resulted in 82
Palestinians dying because they have not been allowed to pass
through checkpoints to access medical care. Twenty-seven were
children. There have been 52 cases of women giving birth at
checkpoints, resulting in the death of 17 newborns. Together with
closures and checkpoints, curfews have imprisoned more than two
million people in their homes (The Palestine Monitor, 2003).
Such devastating environments have a great impact on the mental
health status of Palestinians, and the prevalence of mental health
problems is increasing. As indicated by Thabet (1998), 21 percent
of children below age 12 have anxiety disorders, a figure that's
higher in girls. The study found that living in refugee camps was
strongly associated with anxiety problems. Qouta (1999) found that
36 percent of children reported maltreatment at least once, and 37
percent were exposed to traumatic events. The rate of occurrence of
Post Traumatic Stress Disorder (PTSD) was at 19.5 percent and 63
percent of Palestinian women in Gaza were exposed to traumatic
events. Punamaki et al (1997) showed that traumatic events
increased children's poor perception of parenting involving
punishment, control and rejection, something that is experienced by
boys more than girls. In a sample of former male prisoners between
the ages of 25-39, 40 percent reported PTSD symptoms. They also
reported family and marriage problems, sexual problems and
mal-adaptation (Sarraj, 1996).
Program Profile
The Gaza Community Mental Health Program (GCMHP) was established in
1990 as an independent, non-governmental organization. It adopts a
community-based approach enabling families and communities to cope
with a wide range of mental health problems compounded by human
rights violations, traumatic experiences, poverty and the Israeli
occupation. It serves a wide section of the community through its
community mental health centers and women's centers that are
geographically distributed in the Gaza Strip (North region, Gaza
City, Middle region, Khan Younis and Rafah region), and its
teaching institute.
The program represents a unique and comprehensive approach to the
extensive problem of mental health within Gazan communities. Each
center has its own multidisciplinary team that consists of nurses,
a trained psychiatrist, a psychologist, and social workers. Each
team collaborates with existing health and non-health
organizations. GCMHP's work with adults and children, and in
particular with those exposed to torture and human rights abuse and
their families, emphasizes a community-based approach to tackling
the overwhelming mental health problems among Palestinians in the
Gaza Strip.
In many developing countries, Palestine included, mental disorders
are often a source of fear, and its causes are commonly thought to
be supernatural (WHO 1990). Sufferers and their families feel
stigmatized to approach psychiatric services that are usually seen
as custodial institutions in which troublesome and frightening
people are segregated. Therefore people seek the help of primary
health centers or traditional healers as the main gate of entrance,
presenting their mental health sufferings in physical terms. Afana
(2003) showed that 73 percent of patients at primary health care
clinics have anxiety and depression symptoms, with refugees living
in refugee camps demonstrating a higher prevalence than others. The
ability of general practitioners (GPs) to detect mental disorders
was low (11.6 percent), and 29 percent of patients assessed by GPs
as having mental disorders were already well known to them (Afana,
2002). The prevalence of PTSD among primary health care patients
was 29 percent and higher among women (34.4 percent) than men (21.7
percent). Of those exposed to traumatic experiences, 36.4 percent
met PTSD criteria.
Philosophy and Objectives
The philosophy of the GCMHP is based on the following
principles:
* Enabling families and communities to cope with the wide range of
mental health problems, compounded by human rights violations,
emphasizing a social support network as an effective way to face
mental health issues.
* The responsibility of the health professionals is to move from
intra-personal focus to interpersonal-oriented care.
* Mobilizing local services in the community to assist individuals
in feeling that they are responsible participants, contributing to
their health.
The goal is to ensure that mental health care services in Palestine
are based on the principles of justice, democracy and respect for
human rights with the following objectives:
* To combat the effects of the cycle of violence and systematic
violations of human rights by the Israeli military occupation that
has resulted in an exceptionally high incidence of mental illness
among Palestinians, particularly among women, children and
adolescents.
* To overcome the lack of adequately trained mental health
professionals, and to build indigenous capacity within the
Palestinian state.
* To combat the stigma of mental illness in society, and to
contribute to the development of appropriate and adequate public
policy and practice.
The GCMHP offers four main services:
Clinical service: The GCMHP has become an internationally
recognized, community-based mental health program. A major strength
of the program is the clinical services offered to the Palestinian
population in Gaza by skilled multidisciplinary teams of
psychiatrists, psychologists, social workers and nurses. The
program also has the potential to serve as a training venue for
other health workers in Gaza.
Research: The research unit was established in April 1990. Its goal
is to investigate and analyze the effects of violence on the
Palestinian population, considered the most important psychological
phenomena affecting individuals and families. Children have been
one of the unit's most important target groups. The research unit
has published its findings in several internationally recognized
journals.
Women's empowerment services: Women in Palestinian society have had
to face not only the violence and hardships of occupation, but also
the lack of economic or educational opportunity. During the
Intifada, in addition to being direct victims of Israeli military
violence, Palestinian women faced the psychological and emotional
damage of having fathers, husbands, sons and brothers killed and
imprisoned. Men frequently take out their frustrations on women,
children and other family members.
Training and education: When established, the primary staff
recognized the absence of training institutes in Gaza that could
adequately prepare mental health professionals. To overcome this
difficulty, they embarked on ambitious training activities and
attracted trainers from prestigious institutes around the world.
The trainers provided in-house training to the GCMHP staff in order
for them to offer quality services to the Palestinian population.
Several members of the local staff went abroad to further their
professional skills and have returned with an increased capacity to
assist in the training of local staff. The capacity of the
Palestinian staff to conduct their own culturally sensitive
training has thus increased. Training courses are offered to health
professionals - nurses, social workers, psychologists and GPs - as
well as non-health professionals, including community leaders,
school and kindergarten teachers, and law enforcement agencies.
Religious leaders and mass media staff have also benefited from the
GCMHP training activities.
In 1995, plans were developed to introduce a Postgraduate Diploma
in Community Mental Health for mental health workers of health
disciplines (nurses, GPs, social workers and psychologists) in an
attempt to address the problem and compensate for the total lack of
psychiatric training in Palestine. Training ensures that candidates
have adequate knowledge of state-of-the-art theories, principles
and treatment and prevention strategies used in addressing mental
health concerns. It also imparts training in the influence of human
rights and culture on mental health. The diploma is considered the
first step toward the formation of a Palestinian Institute of
Mental Health and Human Rights that will attract international
students and researchers.
Broad Aims
The postgraduate diploma is a two-year full-time course that is
jointly run by the GCMHP and the Islamic University in Gaza. Seven
other local, regional and international universities contribute to
the teaching and supervision of students. It combines both theory
and the clinical aspects of community mental health and human
rights and provides candidates with a broad knowledge base. The
curriculum is culturally sensitive and community oriented and
critically analyzes the concepts of human rights and mental health.
At the commencement of their first year, students are assigned to
one of the GCMHP teams and are gradually exposed to clinical and
community practice. The diploma is designed to:
* Encourage candidates to explore theoretical concepts in community
mental health and human rights in addition to their practical
applications. Wide exposure to clinical experience enables them to
discover their particular interest in mental health, while learning
about widely different fields and how to integrate them in clinical
practice and research.
* Widen the scope of the medical model and its tendency to focus on
microscopic aspects of mental health. The diploma places the study
of mental health within a wider social, political, environmental
and biological context. Further, it seeks ways to shift psychiatric
therapy away from traditional Freudian concentration on the
individual and unconscious motivational conflicts to move closer to
an emphasis on the social interpersonal care and the role of a
person's environment.
* Place mental health care firmly within the philosophy of the
community-based approach and emphasize the shift from segregated
and self-contained mental health care systems in institutions to
community-based therapy and involvement. It also emphasizes the
change in the role of mental health care professionals from being
providers of mental health care to facilitators of care, thus
enabling individuals to solve their problems using the resources of
the family and community institutions such as schools, mosques,
etc.
* Enable candidates to analyze the applications of health and human
rights and the role they play within the community. It, therefore,
tries to expose students to notions of human rights and to
highlight the links between these concepts.
The Main Lessons
The GCMHP's experience has led us to a number of conclusions. First
and foremost, the planning of a community-based approach to mental
health care must come from within the community, through
professionals who have contact with the community, and not by way
of a political program. Since the approach is multidisciplinary, it
is important to avoid conflict between different disciplines in the
mental health team. Everyone needs to work together. A clear
mandate and job descriptions have to be in place. Professionals
working in community mental health centers have to be trained in
the philosophy of community mental health. It would be a great
weakness to move health professionals from institutional settings
to community settings without the proper training.
One can look at the process of choosing a specific human right to
focus on at the exclusion of others as a selective approach to
human rights. Such a process concentrates on improving the
conditions of one aspect of human rights in a community. Where a
comprehensive approach to human rights focuses on the process of
empowerment and increasing control over all influences that impact
basic rights, a selective approach assumes that political rights
create and ensure control over human rights promotion by
politicians.
This does not mean that selective human rights are not crucial in
addressing certain sufferings such as torture. However, by only
addressing those abuses, the fear is that we constantly risk
addressing only the end result of the problem instead of the root
causes and/or the social conditions underlying these abuses.
Cultivating a comprehensive approach to human rights is a
developmental process. Such a process is established through the
presence of social justice, equity, community development and
social change, the right to health and education, and the right to
live in peace and with dignity. It is a process that requires
people's involvement in decisions related to their lives, as well
as examining the positive and negative conditions that promote
human rights and human rights abuses.
References
Afana Abdel-hamid; Dalgard, Odd Steffen; Bjertness, Espen; and
Grunfeld, Berthol. 2002. The ability of general practitioners to
identify mental health problems among primary care patients in the
Gaza Strip. Journal of Public Health and Medicine 24(4):
326-331.
Afana Abdel-hamid; Dalgard, Odd Steffen; Bjertness, Espen; and
Grunfeld, Berthol. 2002. The prevalence and associated
socio-demographic variables of Post Traumatic Stress Disorder among
patients attending primary health care centers in the Gaza Strip.
Journal of Refugee Studies 15(3): 284-295.
Afana Abdel-hamid; Dalgard, Odd Steffen; Bjertness, Espen; and
Grunfeld, Berthol. 2003. The assessment of mental disorders in
primary health care clinics in the Gaza Strip. Journal of Public
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El Sarraj E., Punamaki RL, Suhaile S. and Summerfield D. 1996.
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Gaza, Palestine
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