Volume 24/2, December 2022, pp. 305-318 | PDF
Maria Helbich and Samah Jabr
Abstract
This paper examines the process of depoliticization of mental health in the occupied Palestinian territories (oPt) and links it to a critical analysis of post-traumatic stress disorder and the role of international humanitarian aid. It is based on a human rights framework that focuses on the right to health and that is instrumental in connecting human rights violations to demands of social justice. Efforts to weaken justice and reparations are analyzed by looking at the role of mental health professionals and assumptions of psychotherapy as a neutral and nonpolitical sphere. By drawing on models of decoloniality and liberation psychology, we advocate for a shift from a decontextualized and individualistic approach to mental health to acknowledging the structural, social, and political oppression that are the underlying factors for suffering in the oPt. In order to alleviate the social suffering of Palestinians and to prevent their victimization, interventions that acknowledge the political nature of mental health ill-being and promote a human rights approach are needed.
Introduction
This paper is based on the belief that in order to make sense of trauma, it is necessary to focus on its correlation with human rights violations. As mental health professionals, we are aware that political conflict, economic hardships, and social tension affect mental health. Yet there is a tendency to overlook the social-political reality of the people we are working with by adhering to the concept of neutrality. In order to truly understand social suffering in the occupied Palestinian territories (oPt), such suffering needs to be connected to the prevalence of human rights violations. This can be achieved by differentiating between a trauma framework and a human rights framework. The former aims at providing a vocabulary for human suffering while the latter can be regarded as a moral order meant to prevent suffering and restore social justice. An integrative model would allow for a perspective that focuses on the contextualization of traumatic events by including historical and sociopolitical dimensions and an intersectional approach to trauma.[1]
This paper argues that the structures of oppression and racial discrimination that determine the life of Palestinians can best be understood when referring to the framework of settler colonialism. Settler colonialism is organized around the acquisition of land, with the aim of eliminating and replacing the native population.[2] Understanding Israel as a settler-colonial project, first and foremost, calls into question its portrayal as a liberal democracy.[3] It contests the claim of Israel that it encountered “a land without people for a people without land” and challenges Israel’s assertion of (1) normality, as a normal democracy and Western society, and (2) exceptionalism, which allows Israel to uphold a brutal system of occupation and to exempt itself from norms and obligations of human rights and international law.[4] We contend that the Palestinian population is facing physical and symbolic elimination that requires a praxis of decolonization and liberation as an answer. The framework of settler-colonialism allows an alignment with other Indigenous and native struggles and, most importantly, dismantles Israel’s claim of exceptionalism by bringing it into comparison with other settler-colonial formations.[5]
In this paper, we begin by providing an overview of the right to health as expressed by the United Nations Special Rapporteur on the right to health and linking it to specific challenges in the oPt. Next, we assess the process of depoliticization of mental health in the oPt, with a particular focus on the role of international humanitarian aid. We then contest the topic of neutrality in mental health, pointing to the need to follow an approach of ethic “non-neutrality” by arguing that the focus on social and structural discrimination should be considered an ethical responsibility of health professionals trying to alleviate the suffering of their patients. Adopting a liberation psychology framework can strengthen this approach and help make sense of suffering and put it in relation to the conditions that create it. We conclude the paper by highlighting the need for mental health professionals to adopt a human rights perspective in order to raise awareness of social injustices that lead to the development of trauma.
The right to health
The right of everyone to the enjoyment of the highest attainable standard of physical and mental health, inclusive of all persons with disabilities, as articulated by United Nations Special Rapporteur Dainius Pūras, has not only been an important step forward in making states aware of their responsibilities to provide quality health care services but has also led to two United Nations resolutions pronouncing mental health as a human right. The right to health approach has been instrumental in highlighting the indivisibility and interconnectedness of all human rights. It engages critically with the dominance of the biomedical model in mental health care and the overemphasis on specialized health care that is prone to reinforcing power imbalances.[6] Through the over-reliance on biomedical interventions aimed at the individual over community-based health initiatives, attention is shifted away from psychosocial and sociopolitical determinants of health and from structural causes of poor mental health.[7] A mental health approach that is not based on the fulfillment of all human rights, inclusive of the principles of empowerment and participation, and that does not frame mental health as a consideration of social justice is likely to reproduce inequalities and structural barriers.[8] We will show in the course of this paper that Palestinian colleagues have been advocating for a greater understanding and acknowledgment of the impact of social and political factors, such as structural oppression and systematic violence, on mental health in the oPt, the lack of which is undermining a rights-based approach to health. The protection of all forms of violence is expressed by the Special Rapporteur as a key element in the realization of the right to health:
Violence needs to be addressed in a comprehensive and proactive way, not only as a cause of serious violations of human rights, but also as a consequence of a lack of political will to effectively invest in human rights, including the right to health.[9]
The community-wide social suffering of Palestinians related to the political violence of the occupation and the settler-colonial regime needs to be recognized as one of the most significant underlying reasons for mental ill-health in the oPt.[10]
The right to health in the oPt is further severely undermined due to restrictions on movements, particularly in the Gaza Strip, which affect not only the general population but also ambulance drivers and medical staff. Access to Jerusalem for medical reasons is dependent on permits, and even emergency cases are frequently delayed at checkpoints. The de-development of health infrastructure on account of the Israeli-imposed blockade in the Gaza Strip has led to shortages of medicine, equipment, and medical supplies.[11]
The right to health relates not only to those in need of services but also to health care workers.[12] There has been a worrying tendency to criminalize humanitarian aid and human rights work around the world, which has become observable in the oPt as well.[13] During the Great March of Return, consisting of large-scale demonstrations in the Gaza Strip in 2018, Israel specifically targeted health care workers, killing three medical workers and injuring at least 115 paramedics and medical workers through live ammunition and tear gas inhalation.[14] The case of 21-year-old Palestinian medic Razan Al-Najjar, who was killed while wearing a white coat and attending to injured demonstrators, has received vast public attention and outcry.[15] The recent labeling of seven Palestinian human rights and civil society organizations dedicated to defending human rights, children’s rights, political prisoners’ rights, and gender justice as “terrorist organizations” has caused widespread concern.[16] These measures by Israel can be regarded as a tool of the oppressor to silence those seeking to hold it accountable for human rights violations and as a direct attack on the right to health through the targeting of organizations that promote international humanitarian law and provide peaceful activities for civil society.
While the right to health stipulates access to quality health care, attention needs to be put on what kind of health care is being propagated by international funding. We examine in this paper how organizations in the oPt are dependent on utilizing Western biomedical treatments in order to receive donor funding. The historical divide between mental and physical health and the resulting underfunding of mental health services—with a simultaneous focus primarily on segregated psychiatric institutions—is another barrier to qualitative health in the oPt, one that has only been exacerbated by the COVID-19 pandemic.[17]
The Special Rapporteur has also addressed the issue of stigma and discrimination in relation to the right to health and has called for measures to ensure that professional health services do not perpetuate stigmatization.[18] The prevalence of judgmental and biased attitudes of service providers in the oPt toward survivors of violence and people suffering from mental health disorders does not foster trust in the system. There is a tendency in society to regard people in need of more specialized mental health services as lazy or as lacking faith or will. Negative perceptions are heightened when it comes to survivors of gender-based violence. Communities often perceive women who seek out shelters or outside help as scandalizing private family matters or breaking families apart. The situation is particularly harsh for women living in East Jerusalem who are governed by Israeli law. Involving Israeli authorities creates an extra barrier in seeking help and makes them more vulnerable to bias and negative perceptions from their community.
The depoliticization of mental health in the occupied Palestinian territories
Until the 1980s, the international community did not particularly focus on the mental health of Palestinians. In the context of the first Intifada, the first uprising against the Israeli occupation, and the associated reporting on Israel’s military violence, not only was the term “trauma” used more and more frequently, but it also became a cause of concern for the humanitarian community.[19] This development coincided with a growing tendency to medicalize and pathologize human experiences, which was exemplified by the emergence of the post-traumatic stress disorder (PTSD).
Derek Summerfield (1999) emphasizes that PTSD can be regarded as the invention rather than the discovery of a psychiatric diagnosis.[20] PTSD is a psychiatric disorder that occurs after experiencing or witnessing a traumatic event, such as a natural disaster, a terrorist act, war, or rape, as well as after being threatened with death, sexual violence, or serious injury.[21] The diagnosis first became official in 1980, in the wake of the aftermath of the Vietnam War, when antiwar activists used it to demand specialized help for veterans. The PTSD diagnosis opened up a legitimate victim status for the veterans in addition to a disability pension.[22] Since then, the diagnosis has had a lasting influence on how experiences of violence are understood and communicated. It is therefore inevitable to see that the “discovery” of the diagnosis of PTSD has sociocultural roots.[23] These roots lie in Western psychological models that claim that PTSD is a problem that can be quantified, measured, and treated by experts. Concepts such as PTSD and the resulting psychological and psychotherapeutic treatment methods reinforce the hegemony and legitimacy of Western expertise in humanitarian aid:
There is too often a one-way transfer, generally north-south, and the question is who has the power to define the problem and make these definitions stick? There has been little independent evaluation of the benefit of trauma programmes but their attractiveness for donors may be because they offer a fashionable, time limited and apparently politically neutral form of intervention that avoids the controversial questions wars throw up.[24]
Summerfield points out another issue associated with the PTSD diagnosis: the problem of decontextualization. The uncritical adaptation of the concept and the language of trauma harbors the danger of depoliticizing and decontextualizing social injustice and the political and sociopolitical conditions of trauma. By reducing trauma to an individual psychological suffering, the history of colonization and the still-existing hegemonic power imbalance are obscured.[25] This is particularly worrying in the context of humanitarian aid, where the necessary reflection on power and ideology and related colonialist tendencies is often lacking.[26]
The clinical and medical trauma discourse is therefore viewed critically, especially against the background of the disregard toward the sociopolitical context of traumatization.[27] Palestinian colleagues have been very vocal about pointing out the problems of reinforcing the diagnosis of PTSD in the oPt, as is the strategy and custom by many international organizations. One problem is that PTSD is characterized by the fact that the traumatic event is in the past (“post”). This term is therefore hardly applicable in a situation of ongoing violations, as in the oPt.[28] Second, the prevailing conflict and the associated systematic discrimination and human rights abuses is what should be pathologized, not people’s reaction to it. The uncritical adoption of the trauma context moves the narrative away from the social and political context and underlying reasons for trauma and reduces it to individual psychological suffering, thus stigmatizing people.[29] The sociocultural conditioning of pain and traumatization requires an approach that is dedicated to the collective meaning of suffering and that strengthens the meaning of social cohesion and solidarity.[30] Otherwise, social suffering will be mistakenly diagnosed as a clinical pathology.
Consequently, an individualistic approach does not suffice when trauma is caused by colonial practices on the collective level.[31] This became especially apparent during the second Intifada in 2000, where, in contrast to the local civil society organizations during the first Intifada, national and international nongovernmental organizations (NGOs) failed to provide mental health services in direct relation to the military violence of the occupation:
Constrained by the availability of funding and the political agenda of the funders, one can safely conclude that the work of these organizations is anything but praxis towards liberation and social justice for the communities they purport to serve.[32]
It seems therefore necessary and urgent to look at the effects of political and systematic violence on Palestinian mental health in order to strengthen the resilience of communities, instead of individualizing their suffering. This can be achieved by moving away from a mental health framework that regards them as individual victims affected by political violence and toward a human rights framework that sees them as rights holders and survivors of a collective experience of violence within a social and political context.[33] It is also necessary to emphasize contextual differences and culture-specific characteristics instead of pretending that reactions to trauma are universal.[34]
International aid especially has been complicit in undermining the resilience of communities by regarding them as “medicalised objects of suffering” rather than as active agents of resilience and resistance.[35] Focusing solely on biomedical factors means that demands for justice and reparation are neglected or put in the background. These tendencies correlate with neoliberal policies and worldviews that put individual responsibility above social accountability. This approach fosters the belief that a “successful life” is linked not to political situations or social conditions but rather to the individual’s ability or inability to shape his or her life.[36] Focus is therefore shifted from those committing crimes (and who should be held accountable) to the individual who is suffering. Further, neoliberal policies regard health services as an economic commodity, thus moving health services from the responsibility of the state to the private sector.[37]
In order to receive financing from international NGOs, many local organizations adopt the trauma discourse and a biomedical approach in their programs. Cindy Sousa and David J. Marshall analyze the phrasing that local Palestinian organizations use in their project proposals when applying for funding from international donors.[38] They conclude that the underlying source of mental health-ill being—the Israeli occupation—is left vague or not mentioned at all. Instead, the potential violence of Palestinian youth or their “educational, social and behavioural problems” are identified as in need of intervention.[39] Similarly, the proposed interventions do not focus on personal empowerment or political advocacy to change the system of political violence, instead individualizing and depoliticizing human rights violations. Many proposals strategically adopt and reproduce a Western neoliberal framework of trauma in order to be eligible for funding.[40] These observations are in line with our own experiences working in local and international organizations in the oPt. On account of international funding, psychological aid programs are offered, but political fears and concerns lead to their political decontextualizing. As a result, the majority of programs take place in a political vacuum.[41] International humanitarian organizations are not only dependent on Israel for issuing visas but also affected by delegitimization, as well as access and administrative restrictions.[42] Instead of challenging the system of structural violence and oppression, many organizations are complicit in ignoring these factors. They are, however, also integral to the depoliticization of collective concerns from the sociopolitical context through the process of “NGO-ization.” NGO-ization highlights the institutionalization, professionalization, depoliticization, and demobilization of movements for social change.[43] Depoliticization processes have played a huge part in weakening efforts for social change in Palestine, not only in regard to mental health but also, for instance, in undermining national sovereignty and the women’s movement.[44] Ibrahim Makkawi presents an intriguing overview of the historical development of civil societies that were instrumental in sustaining the struggle for liberation and providing psychological support for victims of violence.[45] After the Oslo agreement in 1993, Palestine was flooded by mostly Western-funded NGOs, resulting in a disappearance of grassroots civil organizations. While these NGOs are still working with Palestinian communities, they apply individualistic, depoliticized, and decontextualized interventions of counseling and psychotherapy. In order to challenge these approaches of individualization, mental health professionals have emphasized the collective exposure of Palestinians to the political violence of the settler-colonial regime, such as shelling, tear gassings, and the destruction of homes, as well as seeing others being humiliated, injured, arrested, and killed. The focus on collective experiences stands in stark contrast to the tendency of the international community to focus on biomedical methods and individual pathologies.[46]
Despite the fact that the majority of mainstream humanitarian responses display neutrality regarding the political context in Palestine, research shows that responsibility and justice are at the heart of recovery.[47] Palestinian resistance, however, is criminalized by conditions on aid that are put forward by the European Union or the United States Agency for International Development through their “counter-terror measures,” which require civil society organizations to vet their beneficiaries, partners, and subcontractors to prove they are not cooperating with anyone designated as “terrorist.”[48] These measures need to be put into perspective in terms of the ongoing settler-colonial regime and its effort to control the Palestinian population.
The role of mental health professionals
Mental health counseling and psychotherapy are often perceived as power-free and neutral spaces. However, they have always been, and are still today, deeply political.[49] The pretext to act neutrally and objectively can obfuscate dependence on power relations. Further, by taking a neutral role as a mental health professional and by remaining silent on issues of violence or human rights violations, a position can unconsciously be taken and signaled to the patient. If the goal of psychotherapy is the liberation from social constraints and the ability to live in freedom and security, it is necessary to move from a position of passive observation to a growing awareness of political factors that lead to human suffering:
Ignoring such factors [economics, class, violence, leadership, ethnicity, etc.] in therapy constitutes a form of malpractice. Ignoring them outside the clinic constitutes a very dangerous political position, one that cannot be reconciled with fundamental psychological ethical codes. While aspiring to change and well being, therapists cannot just stand aloof and passively (and most unwittingly) take part in the continuation of hardship and distress. Remaining silent, ignorant or passive would make us accomplices to the production of human suffering, and would constitute a betrayal of our basic values as therapists.[50]
We do not suggest that every psychotherapist or mental health professional should necessarily become a political activist. A political stance can be taken precisely by practicing psychotherapy and by being aware of the various sociopolitical factors and the way they shape lives. However, if this perspective is lacking, there is a risk of neglecting or veiling politically relevant conditions and misinterpreting them as intrapsychic states of suffering.
Liberation psychology
When thinking about mental health practice in Palestine, it is relevant to put it into perspective with the liberation psychology approach developed by Ignacio Martón-Baró and with theories of decolonization by Frantz Fanon. Fanon is known for his involvement in struggles against racism, colonialism, and oppression and has contributed extensively to studies of the psychopathology of colonization. He has been instrumental in connecting psychological theory and praxis with political violence and forms of oppression in colonial systems. He stresses the belief that the psychological problems of individuals cannot be separated from their cultural, social, and historical background. By referring to a collective framework, Fanon directly objects to European narcissistic and individualistic psychological thinking.[51] He has further contributed to an understanding of the impacts of subjugation on the psychological mindset of the oppressed by drawing on the phenomenon of the internalization of inferiority, the “epidermalization of inferiority.”[52] For Fanon, the solution to breaking the cycle of internalization is to be found in resistance and in directing feelings outward, to those who oppress, instead of inward.[53]
Martín-Baró, in following Paolo Friere’s thinking on “critical consciousness,” considers that liberation can be achieved through critical self-examination or “conscientization.” This process requires understanding the “mechanisms of oppression and dehumanization” by focusing on the conditions that create trauma.[54] The role of the psychologist would be “to examine these dehumanizing relations and to play a role in the collective political project of changing them.”[55]
Although psychotherapy is traditionally considered a highly individualistic process, recent publications have pointed to the inherent political dimension of psychoanalytic practice. The compelling publication Psychoanalysis under Occupation by Lara and Stephen Sheehi highlights how Palestinian clinicians regard the practice of psychotherapy as a form of resistance and a counter-measure to attempts to erase the national identity. The lived reality of settler-colonial practices and the violence of the occupation regime are being confronted as a means of conscientization.[56] Psychotherapy thus possesses the potential for social and political mobilization and for attending to those target groups that are especially marginalized and vulnerable due to the occupation practices. One of these groups are female ex-prisoners, whose standing in Palestinian society is complex and who, contrary to male ex-prisoners, are not glorified because of their involvement in the national struggle. One of the authors, in cooperation with the human rights organization Addameer, provides mental health services to a group of female ex-prisoners. Instead of pathologizing their involvement in the liberation struggle, we regard their wish for freedom and for national sovereignty as a liberation from an imposed state of helplessness. Providing services to ex-prisoners is particularly important because of their marginalization due to the aforementioned constrictions imposed on aid in regard to terrorism. When Addameer was recently raided and forcibly closed by Israeli occupation forces as one of the seven human rights organizations that were labeled as terrorist organizations, the therapy sessions were held via Zoom in order to guarantee the continuation of the services.[57] Our experience in Palestine has shown that offering mental health services requires us to learn from the experiences and adapt to the needs of each group, even in unprecedented situations.
Working on mental health in Palestine obligates practitioners to constantly confront the settler-colonial system of power and violence. Relying solely on diagnosis and individual therapy methods does not reflect the reality of working as a mental health provider. One of the authors has been involved in the case of Ahmad Manasra, a 20-year-old Palestinian who has been detained in Israeli prisons since he was 14 years old, despite suffering from serious mental health conditions.[58] Being part of an international campaign, advocating for the rights of mental health patients, raising awareness, supporting the parents of Ahmad, and writing reports for Israeli courts are as much part of the work of a mental health practitioner in Palestine as classical psychotherapeutic practice. These experiences of working under a settler-colonial regime stand in stark contrast to claims of ethical neutrality, as is discussed below.
Towards an ethic non-neutrality
The claim that the practice of psychotherapy is carried out independently of the cultural and political context deprives mental health professionals of the ability to work in environments in which the political affects the personal and individual sphere.[59] This is especially relevant in the oPt, where the occupation impacts every aspect of life. Here, we will explore in more depth why the claim of neutrality in the mental health sector is ethically problematic and why remaining “neutral” or “objective” is a luxury reserved for those who do not belong to the marginalized group.
There appears to be a significant distortion in the field of mental health about what professional neutrality entails. Neutrality is defined as maintaining “an observing stance, while avoiding siding with any of the forces involved in the patient’s conflict” or as refraining from “expressing judgments.”[60] Hollander highlights how psychoanalytical organizations did not speak out about gross human rights violations during the military dictatorship in Argentina, instead distancing themselves from the political and social context by claiming professional neutrality or “abstinence.”[61] Only a small number of psychoanalysts chose to practice psychotherapy by highlighting the dialectical relationship between the subjectivity of patients and their social reality. These mental health professionals believed that in order to be conscientious psychotherapists, they needed to take an oppositional position to the oppressor and inflictor of pain and violence:
Under such conditions, assuming a position of neutrality would contravene the possibility of securing the trust and alliance of one’s patients. These psychoanalysts thus embraced a therapeutic perspective they termed “ethic nonneutrality.” In the context of working with victims of state terror, there was no room to be a bystander, even within the psychoanalytic frame.[62]
Disregarding the social and political sphere as an integral part of our own and our patients’ lives would block off discussion and reflection of intrapsychic processes. Both individual intrapsychic suffering and sociopolitical processes need to be acknowledged. Treating trauma as a purely intrapsychic process would deny the social dimension of suffering. However, if the focus is placed only on the political and collective aspects of trauma, the real individual wounds are neglected.[63] This challenging dichotomy needs to be constantly reflected.
Regarding neutrality as a therapeutic ideal discourages professional engagement with relevant political topics, moral concerns, and social challenges of our time. The strategy of depoliticization very easily becomes a cover-up for unequal power dynamics.[64] For decades, political factors such as gender, ethnicity, class, religion, and politics have been regarded as irrelevant to psychotherapeutic practices. Since then, professionals have become aware of the fact that by not speaking up about social and structural injustices, they become complicit in a system that oppresses others. Mental health professionals work with patients to ensure that they live physically and mentally protected, reflecting with them on how they can better care for themselves or others. Ignoring how political factors lead to human suffering would constitute a gross malpractice, which cannot be reconciled with our ethical codes as therapists.[65] Taking a stand against structural injustice is the condition for empowerment and for alleviating suffering: by being aware of the causes of social suffering of our patients, we can help reduce self-blame, victimhood, and helplessness.
A call for professional solidarity and social justice
Mental health professionals, among other professionals in the social and health sector, play a unique role in advocating for professional solidarity and social justice in the face of human rights violations. Since social suffering tends to remain hidden and invisible, it is among the responsibilities of professionals to fight against this social invisibility by becoming a spokesperson and by advocating for social policies.[66] There is a political significance to social suffering: “Social suffering is hence part of a social critique that is also a social diagnosis and an attempt to find political solutions.”[67] So far, as already outlined in this paper, mental health discourses have concentrated to a much greater extent on the inner psychic conditions of suffering. Private suffering needs to be translated into public suffering with the help of a mental health professional who denies neither the outside conditions nor the intrapsychic suffering.[68]
To victims of human rights violations, apart from the treatment of their individual wounds, social justice is the most effective and reparative method of alleviating suffering. Otherwise, as Chris Beyrer rightly asks, if human rights violations receive impunity, what hope do survivors of injustice have?[69] This question is particularly relevant in the oPt, where settler violence is part of the everyday life of Palestinians. Reports from national and international organizations demonstrate that Israeli security forces not only allow settlers to use force against Palestinians and their property but also escort them to or participate in the acts of violence.[70] The majority of perpetrators of violence are exempt from punishment and are not held accountable for the consequences of their actions: a study by the human rights organization Yesh Din revealed that between 2005 and 2019, 91% of investigations into settler violence were closed without charge.[71]
The right to health cannot be exercised if other human rights are undermined, making it critical to ensure that the trauma debate is included within a wider human rights framework.[72] Mental health professionals working with victims of human rights violations committed in Chile in the 1980s and 90s have spoken out about the inadequacy of the term “disorder.”[73] They argue that by diagnosing victims as suffering from a disorder, acts of cruelty are justified. Individual and specialized care should by no means be denied to individuals. However, “it makes an enormous difference that we regard them less as individually disturbed and more as persons suffering the consequences of a disturbed society.”[74] When sociopolitical acts of injustice—for instance, torture—are not declared as such and are instead deemed individual experiences, we play into the hands of the victimizer and repeat their denial, thus victimizing the survivor all over again.[75]
We believe that this commitment to social justice and solidarity is particularly called for in the oPt, where mental health professionals have long been advocating for a human rights discourse. This shift in perspective allows for a focus on the effects of colonial practices and systematic violence on the mental well-being of Palestinians and highlights the fact that these are the most relevant and profound causes of community problems in the oPt. It is also a powerful tool for taking a stance against the so-called professional neutrality of mental health professionals by putting the sociocultural environment and conditions of oppression, discrimination, and injustice into focus and using this knowledge for health considerations of individuals and communities.[76] Yet we also agree that within the health sector “there is a visible decline in the willingness to take on these issues once considered acceptable or even crucial. One can only posit this is because they are now considered too controversial or even radical.”[77] Supporting publications that ensure the health and human rights of all people is one measure suggested by Sofia Gruskin to counteract this tendency.[78] This has direct bearings on the oPt, where we see a general shortage of Palestinian-generated research in comparison to other countries. Participating in conferences requires paying a registration fee, which puts a great financial burden on Palestinian health professionals, frequently constituting half a month’s salary. Even if conference fees are covered, travel restrictions pose another barrier in attending professional events in other countries. Likewise, many publications in scientific journals are contingent on submission fees.
New Israeli rules on entry to the West Bank, called “Procedure for Entry and Residence for Foreigners in Judea and Samaria Area,” which came into effect on October 20, 2022, have stirred outrage among Palestinian legal experts and academics.[79] The set of rules regulates who is allowed to enter the West Bank, teach in Palestinian universities, or visit universities as a foreign student; it also regulates what types of organizations are allowed to host volunteers. These rules are regarded as a new move to restrict academic and professional exchange and to further silence and isolate Palestinian scholars.[80]
It is also worth mentioning that criticism of Israel’s policies and the occupation is all too quickly labeled as “anti-Semitic,” particularly when adhering to the definition of antisemitism adopted by the International Holocaust Remembrance Alliance in 2016, which more often than not is used to stifle any criticism of Israel.[81] It is a very powerful and effective strategy to silence people and keep them from making statements about Israel’s oppressive political system. Above all, it is an attempt to delegitimize pro-Palestinian movements. This strategy has, unfortunately, also resulted in instilling fear among mental health professionals in terms of speaking out about Israel’s human rights violations, and frequently results in avoidance of these topics for fear of personal and professional backlash. All these obstacles have a significant impact on counteracting mainstream ideas of mental health in the oPt and on allowing Palestinian professionals to make their voices heard.
Conclusion
Solidarity starts by acknowledging human rights violations and by putting the blame on the victimizer, not the victims who react to these experiences. Who better than mental health professionals are able to understand how constant fear, pain, and terror influence individuals? As psychotherapists or mental health workers, we are confronted with the question of how we regard our ethical role and how we intend to act on it:
Do we see ourselves as an active part of society, or do we consider the therapeutic space a “nonpart” of society? Work with trauma victims confronts us with questions of social involvement that are inescapable, even if we are not always aware of them.[82]
However, trauma theory has reached an impasse worldwide: it has developed into a medical, symptom-oriented approach that produces methods of therapy that stubbornly disregard sociopolitical discourses and that disguise social and political problems as pathological disorders.[83]
In general, there are little efforts to address the effects of trauma on an international policy level. Yet in order to respond to trauma in the oPt, a political solution is required not only to reduce physical and psychological threats but also to establish historical, political, and moral justice.[84] Impunity can be understood not just as the absence of court sentences against human rights offenders but in a broader sociocultural sense as the societal negation of the suffering of victims.[85] There is no doubt that legal, social, and moral justice have a reparative function, both for the individual and for society as a whole. Consequently, when solidarity and calls for justice are silenced by the powerful party, when Israel is not held accountable for its violation of international laws, and when victims of violations are framed as terrorists, the lack of international solidarity and efforts of redemption will affect the mental well-being of Palestinians.[86] If the prevention of trauma is a serious aim of the international community, focus has to be put on the root causes of trauma and on demands of social justice. This would enable a paradigm shift from the question “What’s wrong with you?” to “What’s happened to you?”[87] This approach would challenge the “absence of a collective moral outrage and a deafening silence on massive violations of health and human rights,” which has become observable in today’s world and poses one of the biggest challenges nowadays.[88]
A stronger understanding of the political and social implications of trauma and a more active role in relation to social injustices and human rights violations are essential against the background of the ethical standards of our profession. As mental health professionals, our commitment to advancing human rights can be shown by highlighting the pathogenic context in which trauma develops and by demanding social justice on a political level.
Maria Helbich, MSc, is a psychotherapist from Vienna, Austria, specializing in gender-based violence and trauma and is currently based in Palestine.
Samah Jabr is a psychiatrist who practices in East Jerusalem and the West Bank and is
head of the Mental Health Unit within the Palestinian Ministry of Health.
Please address correspondence to Maria Helbich. Email: maria.m.helbich@gmail.com.
Competing interests: None declared.
Copyright © 2022 Helbich and Jabr. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction.
References
[1] L. D. Butler and F. M. Critelli, “Traumatic Experience, Human Rights Violations, and Their Intersection,” in L. D. Butler, F. M. Critelli, and J. Carello (eds), Trauma and Human Rights: Integrating Approaches to Address Human Suffering (London: Palgrave Macmillan, 2019).
[2] R. Busbridge, “Israel-Palestine and the Settler Colonial ‘Turn’: From Interpretation to Decolonization,” Theory, Culture and Society 35/1 (2018).
[3] I. Pappé, “Shtetl Colonialism: First and Last Impressions of Indigeneity by Colonised Colonisers,” Settler Colonial Studies 2/1 (2012).
[4] D. Lloyd, “Settler Colonialism and the State of Exception: The Example of Palestine/Israel,” Settler Colonial Studies 2/1 (2012), p. 62. See also R. Lentin, “Race and Surveillance in the Settler Colony: The Case of Israeli Rule over Palestine,” Palgrave Communications 3/1 (2017).
[5] O. J. Salamanca, M. Qato, K. Rabie, and S. Samour, “Past Is Present: Settler Colonialism in Palestine,” Settler Colonial Studies 2/1 (2012).
[6] Human Rights Council, Report of the UN Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, UN Doc. A/HRC/35/21 (2017); United Nations General Assembly, Interim Report of the UN Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, UN Doc. A/73/216 (2018); Human Rights Council, Report of the UN Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, UN Doc. A/HRC/41/34 (2019); Human Rights Council, Resolution 36/25, UN Doc. A/HRC/36/25 (2017).
[7] L. Cosgrove and A. F. Shaughnessy, “Mental Health as a Basic Human Right and the Interference of Commercialized Science,” Health and Human Rights Journal 22 (2020).
[8] F. Mahomed, “Addressing the Problem of Severe Underinvestment in Mental Health and Well-Being from a Human Rights Perspective,” Health and Human Rights Journal 22 (2020).
[9] Human Rights Council, Report of the UN Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, UN Doc. A/HRC/29/33 (2015).
[10] See, for example, B. Wispelwey and Y. Abu Jamei, “The Great March of Return: Lessons from Gaza on Mass Resistance and Mental Health,” Health and Human Rights Journal 22 (2020); R. Giacaman, “Social Suffering, the Painful Wounds Inside,” American Journal of Public Health 107/3 (2017); M. Helbich and S. Jabr, “Mental Health under Occupation: An Analysis of the De-politicization of the Mental Health Discourse in Palestine and a Call for a Human Rights Approach,” International Journal of Human Rights in Healthcare (2021).
[11] Al-Haq, Parallel Report to the UN Committee on Economic, Social and Cultural Rights for Its List of Issues on The State of Palestine’s Initial Report (2021).
[12] Human Rights Council (2015, see note 9).
[13] L. Rubenstein, “War, Political Conflict, and the Right to Health,” Health and Human Rights Journal 22 (2020).
[14] Amnesty International, “Six Months On: Gaza’s Great March of Return,” https://www.amnesty.org/en/latest/campaigns/2018/10/gaza-great-march-of-return/.
[15] D. Mills, M. Gilbert, and B. Wispelwey, “Gaza’s Great March of Return: Humanitarian Emergency and the Silence of International Health Professionals,” BMJ Global Health (2019).
[16] See, for example, “UN Experts Condemn Israel’s Designation of Palestine Rights Defenders as Terrorist Organisations,” UN News, https://news.un.org/en/story/2021/10/1103982; Office of the United Nations High Commissioner for Human Rights, “UN Experts Condemn Israeli Suppression of Palestinian Human Rights Organisations,” https://www.ohchr.org/en/press-releases/2022/08/un-experts-condemn-israeli-suppression-palestinian-human-rights.
[17] W. Hammoudeh, S. Jabr, M. Helbich, and C. Sousa, “On Mental Health amid COVID-19,” Journal of Palestine Studies 49/4 (2020).
[18] Human Rights Council, Report of the UN Special Rapporteur (2017, see note 6).
[19] Y. Rabaia, R. Giacaman, and V. Nguyen-Gillham, “Violence and Adolescent Mental Health in the Occupied Palestinian Territory: A Contextual Approach,” Asia-Pacific Journal of Public Health 22/3 (2015). See also R. Giacaman, Y. Rabaia, V. Nguyen-Gillham, et al., “Mental Health, Social Distress and Political Oppression: The Case of the Occupied Palestinian Territory,” Global Public Health 6/5 (2011).
[20] D. Summerfield, “A Critique of Seven Assumptions behind Psychological Trauma
Programmes in War-Affected Areas,” Social Science and Medicine 48 (1999).
[21] American Psychiatric Association, “What Is Posttraumatic Stress Disorder?,” https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd.
[22] Summerfield (1999, see note 20). See also D. Becker, Die Erfindung des Traumas: Verflochtene Geschichten (Gießen: Psychosozial Verlag, 2014).
[23] Ibid.
[24] Ibid., p. 1459.
[25] L. Meari, “Reconsidering Trauma: Towards a Palestinian Community Psychology,” Journal of Community Psychology 43/1 (2015).
[26] Becker (2014, see note 22).
[27] P. Andreatta, “Traumatisierung von Kindern durch Krieg und Flucht sowie ein kritischer Blick auf den klinischen Traumadiskurs,“ Psychologie & Gesellschaftskritik 42/2 (2018). See also Becker (2014, see note 22); D. Becker, “Migration, Flucht und Trauma: Der Trauma-Diskurs und seine politischen und gesellschaftlichen Bedeutungen,” in E. Forster, I. Bieringer, and F. Lamott (eds), Migration und Trauma: Beiträge zu einer reflexiven Flüchtlingsarbeit (Münster: LIT-Verlag, 2003); D. Summerfield and F. Hume, “War and Posttraumatic Stress Disorder: The Question of Social Context,” Journal of Nervous and Mental Disease 181/8 (1993), p. 522; A. Young, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder (Princeton: Princeton University Press, 1995).
[28] S. Jabr, “What Palestinians Experience Goes beyond the PTSD Label,” Middle East Eye (February 7, 2019),
https://www.middleeasteye.net/opinion/what-palestinians-experience-goes-beyond-ptsd-label. See also O. Goldhill, “Ongoing Traumatic Stress Disorder” (January 2019), https://qz.com/1521806/palestines-head-of-mental-health-services-says-ptsd-is-a-western-concept/; A. H. Afana, D. Pedersen, H. Rønsbo, et al., “Endurance Is to Be Shown at the First Blow: Social Representations and Reactions to Traumatic Experiences in the Gaza Strip,” Traumatology 16/4 (2010).
[29] Meari (see note 25); Becker (2014, see note 22).
[30] R. Giacaman, R. Khatib, L. Shabaneh, et al., “Health Status and Health Services in the Occupied Palestinian Territory,” Lancet 373 (2009).
[31] I. A. Makkawi, “Towards an Emerging Paradigm of Critical Community Psychology in Palestine,” Journal of Critical Psychology, Counselling and Psychotherapy 9/2 (2009).
[32] Ibid., p. 80.
[33] C. Sousa and D. J. Marshall, “Political Violence and Mental Health: Effects of Neoliberalism and the Role of International Social Work Practice,” International Social Work 60/4 (2015).
[34] D. Summerfield, “Addressing Human Response to War and Atrocity: Major Challenges in Research and Practices and the Limitations of Western Psychiatric Models,” in R. J. Kleber, C. R. Figley, and B. P. R. Gersons (eds), Beyond Trauma: Cultural and Societal Dynamics (New York: Springer Science + Business Media, 1995). See also Becker (2014, see note 22).
[35] Sousa and Marshall (2015, see note 33), p. 4.
[36] A. Grubner, Die Macht der Psychotherapie im Neoliberalismus. Eine Streitschrift (Wien: Mandelbaum Kritik & Utopie, 2017).
[37] A. R. Chapman, “The Right to Health: Then, Now and a Call to Arms,” Health and Human Rights Journal 22/1 (2020).
[38] Sousa and Marshall (2015, see note 33).
[39] Ibid., p. 5.
[40] Ibid.
[41] Becker (2014, see note 22).
[42] P. Beaumont, “Israel Denies Visas to Staff from ‘Hostile’ Human Rights Watch,” Guardian (February 24, 2017), https://www.theguardian.com/world/2017/feb/24/israel-denies-visa-to-hostile-human-rights-watch-and-warns-it-is-assessing-other-groups; United Nations Office for the Coordination of Humanitarian Affairs, “Humanitarian Operations Undermined by Delegitimization, Access Restrictions, and Administrative Constraints” (2019), https://www.ochaopt.org/content/humanitarian-operations-undermined-delegitimization-access-restrictions-and-administrative.
[43] A. Choudry and D. Kapoor, “Introduction: NGOization: Complicity, Contradictions and Prospects,” in A. Choudry and D. Kapoor (eds), NGOization: Complicity, Contradictions and Prospects (London: Zed Books, 2013).
[44] See S. Hanafi and L. Tabar, “The Intifada and the Aid Industry: The Impact of the New Liberal Agenda on the Palestinian NGOs,” Comparative Studies of South Asia, Africa and the Middle East 23 (2003). See also I. Jad, “The NGO-isation of Arab Women’s Movements,” IDS Bulletin 35 (2004).
[45] I. Makkawi, “Towards an Emerging Paradigm of Critical Community Psychology in Palestine,” Journal of Critical Psychology, Counselling and Psychotherapy 9/2 (2009).
[46] R. Giacaman, “Reframing Public Health in Wartime: From the Biomedical Model to the ‘Wounds Inside’,” Journal of Palestine Studies 47/2 (2018).
[47] C. Sousa and D. J. Marshall, “Political Violence and Mental Health: Effects of Neoliberalism and the Role of International Social Work Practice,” International Social Work 60/4 (2017).
[48] B. Alloush, “Overcoming the Hurdles: The Struggle of Palestinian Humanitarian NGOs,” Tahrir Institute for Middle East Policy (2021), https://timep.org/commentary/analysis/overcoming-the-hurdles-the-struggle-of-palestinian-humanitarian-ngos/. See also T. Dana, “Criminalizing Palestinian Resistance: The EU’s Additional Condition on Aid to Palestine,” Al Shabaka (2020), https://alshabaka.org/commentaries/criminalizing-palestinian-resistance-the-eu-new-conditions-on-aid-to-palestine/.
[49] Grubner (see note 36).
[50] N. Avissar, “Psychotherapy and Political Activism: Examining the Israeli-Palestinian Case,” Psychoanalysis, Culture and Society 13/2 (2008), p. 170.
[51] R. Marton, “The Right to Madness: Les luttes contre la psychiatrie institutionnelle en Israël,” CSPRP Conférence: Penser aujourd’hui à partir de Frantz Fanon (2007), http://www.csprp.univ-paris-diderot.fr/Penser-aujourd-hui-a-partir-de-171.
[52] F. Fanon, Black Skin, White Masks (London: Pluto Press, 1952/2008).
[53] F. Fanon, The Wretched of the Earth (London: Penguin Modern Classics, 1961/2001).
[54] I. Martín-Baro (ed), Writings for a Liberation Psychology (Cambridge: Harvard University Press, 1996).
[55] D. J. Marshall and C. Sousa, “Decolonizing Trauma: Liberation Psychology and Childhood Trauma in Palestine,” in T. Skelton, C. Harker, and K. Hörschelman (eds), Conflict, Violence and Peace (Singapore: Springer, 2017), p. 292.
[56] L. Sheehi and S. Sheehi, Psychoanalysis under Occupation: Practicing Resistance in Palestine (New York: Routledge, 2022).
[57] Office of the United Nations High Commissioner for Human Rights, “UN Experts Condemn Israeli Suppression of Palestinian Human Rights Organisations,” https://www.ohchr.org/en/press-releases/2022/08/un-experts-condemn-israeli-suppression-palestinian-human-rights.
[58] Palestine-Global Mental Health Network, “Mental Health Workers Demand Israel Release Prisoner Ahmad Manasra,” Mondoweiss (2022), https://mondoweiss.net/2022/06/mental-health-workers-demand-israel-release-prisoner-ahmad-manasra/.
[59] W. Elasady, “Fighting the Anti-BDS Backlash,” Socialist Worker (October 3 2016), https://socialistworker.org/2016/10/03/fighting-the-anti-bds-backlash.
[60] F. Yeomans and E. Caligor, “What Is Neutrality in Psychotherapy Anyway?,” Psychiatric News (2016); American Psychiatric Association, “Neutrality,” in Dictionary of Psychology, https://dictionary.apa.org/neutrality.
[61] Becker (2014, see note 22), p. 44. See also N. C. Hollander, “Psychoanalysis and the Problem of the Bystander in Times of Terror,” in L. Layton, N. C. Hollander, and S. Gutwill (eds), Psychoanalysis, Class and Politics: Encounters in the Clinical Setting (New York: Routledge, 2006).
[62] Hollander (see note 61), p. 159.
[63] Becker (2014, see note 22).
[64] M. Kemp, “Dehumanization, Guilt and Large Group Dynamics with Reference to the West, Israel and the Palestinians,” British Journal of Psychotherapy 27/4 (2011).
[65] Avissar (2008, see note 50).
[66] E. A. Bowen, N. S. Murshid, A. Brylinski-Jackson, et al., “Moving toward Trauma-Informed and Human Rights-Based Social Policy: The Role of the Helping Professions,” in L. D. Butler, F. M. Critelli, and J. Carello (eds), Trauma and Human Rights: Integrating Approaches to Address Human Suffering (London: Palgrave Macmillan, 2019).
[67] E. Renault, “A Critical Theory of Social Suffering,” Critical Horizons 11/2 (2010), p. 238.
[68] Becker (2014, see note 22).
[69] C. Beyrer, “Impunity: Undermining the Health and Human Rights Consensus,” Health and Human Rights Journal 22/1 (2020).
[70] B’Tselem – The Israeli Information Center for Human Rights in the Occupied Territories, Playing the Security Card: Israeli Policy in Hebron as Means to Effect Forcible Transfer of Local Palestinians, https://www.btselem.org/publications/summaries/201909_playing_the_security_card. See also Yesh Din, Yitzhar – A Case Study: Settler Violence as a Vehicle for Taking Over Palestinian Land with State and Military Backing, https://www.yesh-din.org/en/yitzhar-a-case-study-settler-violence-as-a-vehicle-for-taking-over-palestinian-land-with-state-and-military-backing/
[71] Yesh Din, Data Sheet, December 2019: Law Enforcement on Israeli Civilians in the West Bank, https://www.yesh-din.org/en/data-sheet-december-2019-law-enforcement-on-israeli-civilians-in-the-west-bank/. See also United Nations Office for the Coordination of Humanitarian Affairs, “Unprotected: Settler Attacks against Palestinians on the Rise amidst the Outbreak of COVID-19,” Humanitarian Bulletin (June 22, 2020), https://www.ochaopt.org/content/unprotected-settler-attacks-against-palestinians-rise-amidst-outbreak-covid-19.
[72] D. Puras, “Challenges in Promoting the Interdependence of all Human Rights,” Health and Human Rights Journal 22/1 (2020). See also Summerfield (1995, see note 34).
[73] D. Becker, “The Deficiency of the Concept of Posttraumatic Stress Disorder When Dealing with Victims of Human Rights Violations,” in R. J. Kleber, C. R. Figley, and B. P. R. Gersons (eds), Beyond Trauma: Cultural and Societal Dynamics (New York: Springer Science + Business Media, 1995). See also Becker (2014, see note 22).
[74] Becker (1995, see note 73), p. 104.
[75] Ibid.
[76] Makkawi (2009, see note 31).
[77] S. Gruskin, “Reflections on 25 Years of Health and Human Rights: History, Context, and the Need for Strategic Action,” Health and Human Rights Journal 22/1 (2020).
[78] Ibid.
[79] Coordination of Government Activities in the Territories, “Procedure for Entry and Residence of Foreigners in the Judea and Samaria Area” (February 20, 2022), https://www.gov.il/en/departments/policies/judeaentry2022.
[80] “New Israeli Rules on Foreigners Visiting West Bank Stir Outrage,” Al Jazeera (April 27, 2022). See also M. Omer-Man, “Israel’s Restrictions on Foreigners Traveling to the West Bank Just Got 92 Pages Worse,” Democracy for the Arab World Now (2022), https://dawnmena.org/israels-restrictions-on-foreigners-traveling-to-the-west-bank-just-got-92-pages-worse/.
[81] See, for example, J. Butler, “No, It’s Not Anti-semitic,” London Review of Books 25/16 (2003); O. Bartov, “Criticism of Israel and Its Policies Isn’t Antisemitism,” Haaretz (2021), https://www.haaretz.com/opinion/.premium-criticism-of-israel-and-its-policies-isn-t-antisemitism-1.9668517; H. Bresheeth-Zabner, An Army Like No Other: How the Israel Defense Forces Made a Nation (London: Verso, 2020).
[82] D. Brom and E. Witztum, “When Political Reality Enters Therapy: Ethical Considerations in the Treatment of Posttraumatic Stress Disorder,” in R. J. Kleber, C. R. Figley, and B. P. R. Gersons (eds), Beyond Trauma: Cultural and Societal Dynamics (New York: Springer Science + Business Media, 1995), p. 247.
[83] Becker (2014, see note 22).
[84] See R. Batniji, Y. Rabaia, V. Nguyen-Gillham, et al., “Health as Human Security in the Occupied Palestinian Territory,” Lancet 373/9669 (2009); Giacaman et al. (2009, see note 30); Makkawi (2009, see note 31).
[85] K. Rauchfuss, “‘Die Tragödie beginnt erst nach dem Ende der Verbrechen‘. Eine Kultur der Straflosigkeit behindert die Rehabilitation von Überlebenden schwerer Menschenrechtsverletzungen, ” PERIPHERIE 109/110- 28 (2008).
[86] Human Rights Council, Israeli Settlements in the Occupied Palestinian Territory, including East Jerusalem, and in the Occupied Syrian Golan, UN Doc. A/HRC/28/44 (2015). See also United Nations General Assembly, Report of the Special Rapporteur on the Situation of Human Rights in the Palestinian Territories Occupied since 1967, UN Doc. A/HRC/25/67 (2014); International Court of Justice, Legal Consequences of the Construction of a Wall in the Occupied Palestinian Territory, https://www.icj-cij.org/en/case/131.
[87] L. S. Bloom, “The Sanctuary Model: Developing Generic Inpatient Programs for the Treatment of Psychological Trauma,” in M. B. Williams and J. F. Sommer (eds), Handbook of Post-Traumatic Therapy, a Practical Guide to Intervention, Treatment, and Research (Santa Barbara, CA: Greenwood Publishing, 1994), p. 476.
[88] R. Khosla, “Health and Human Rights at a Crossroads,” Health and Human Rights Journal 22/1 (2020).