Interview: Therapy in a Traumatised Society

Fran Miller is an Art Psychotherapist who has worked for Medecins Sans Frontieres in Afghanistan, the Phillipines, Indonesia, Uganda, Northern Sudan, Liberia and Palestine. Here she talks to Mental Nurse about the challenges of trying to provide mental health support in the West Bank of Palestine.

What sort of services does MSF provide in the Palestinian Territories?

MSF teams work in Hebron and Nablus on the West Bank, and in Gaza. The programs provide medical and mental health treatment and support to the local populations. Last year MSF did an assessment in Jenin on the West Bank to see if the medical/mental health needs needed support. From the assessment it was clear that whilst the medical needs were being met by the Palestinian Ministry of Health and UN Relief and Works Agency, additional mental health support was needed in Jenin Camp.

Can you tell us about your own project?

As field co-ordinator my role was to set up the mental health program in the camp. Once the program was up and running additional psychologists would join the team. As in any start up project its about networking, collaboration with other professionals and talking with potential beneficiaries. There are also the practical logistical details, recruitment of the national team etc. The MSF co-ordination team in Jerusalem had paved the way at national level for the project; our job was to work in the camp to set up a program that would meet the needs of the people.

What was the actual need that was in the area?

The objective for MSF in Jenin was that we would be working with the direct victims of violence as opposed to the indirect victims. In Palestine almost everybody’s an indirect victim of violence. It’s a small area, so everybody’s affected. In 2002 Jenin Camp was the site of one of the bloodiest conflicts. In the past there have been many Israeli Defence Force incursions into the camp, although we were told that these have decreased in recent months. We would be working with people who had been affected by the violence, or had members of their family detained by the IDF. Some people in the camp also talked about the violence from within the camp, almost everyone mentioned the high levels of aggression from young people and their fear that traditional family structures where breaking down.

The work is to do with trauma, depression, anxiety and loss. Interventions are short-term and based on supporting people in the here and now. Its about looking very much at the whole package that goes with trauma in these kinds of areas. What we’re talking about here is chronic violence; you can get specific episodes of Post-Traumatic Stress Disorder which we treat with CBT, but a lot of the time you’re getting the fallout of cumulative trauma, with whole families and communities starting to break down.

With one-off trauma it’s a single event, there’s many coping mechanisms that existed before the trauma, and its about treating individuals and reconnecting people with natural support mechanisms in families and community. But with long-term trauma it’s more complex.

Can you give examples of the sort of things people might have seen or experienced?

Where there is chronic conflict, often you can get a real breakdown in family and community. The impact of long-term conflict on the West Bank means that most people have not really experienced a period of real stability for a very long time. From the people that we talked with, particularly the women, there was a sense of hopelessness about the future. They talked about men having lost their role within families either because of absence or difficulties in being able to provide and protect their families in the expected way.

Obviously, there is violence that is external to the camp, and also violence within the camp, When the violence comes from outside, as it can in the form of raids, one of the things that people found most difficult to deal with is the unpredictability of it. You never quite know when there is a threat coming or if the situation is going to become unstable again.

Because you can be raided at any time?

Yes, and it’s not a fantasy. It’s quite a possibility. There are detentions, which are often without trial. You don’t know when people are going to be coming back, how long they’re going to be in jail for, so families are broken up. People described the violation when somebody comes in and bulldozes your house, or if armed soldiers come into your family home – there’s a lot of noise, a lot of guns. So part of our work there would be to work with the immediate victims of that type of violence, and to be able to listen to them about how they felt, treat symptoms if necessary and reconnect them with existing support networks.

The camp is unsettled, and if you have key attachment figures who are lost in some way, or if they are “defeated” as a lot of parents used to put it when I was in Northern Uganda, by these sorts of events, then that produces all sorts of emotional and behavioural difficulties; particularly with children and adolescents. For children it can be particularly difficult; the medical team in the camp and other psychosocial groups reported high levels of enuresis [bedwetting] and other anxiety related disorders. It’s a generation of young people who grew up with the direct experience of violence and or fear of violence.

Here in the West we’re familiar with how things like childhood abuse can disrupt peoples’ attachments, and how this can lead to conditions like borderline personality disorder.

Yes, and in a way these things can happen in Britain, but what’s happening here is whole communities that have been subjected to this. An abused individual here has normalised aspects of society to compare their experience to, but in these communities the violence itself is normalised. Without the outside experience, there’s nothing to measure it against.

The Jenin MSF programme was never put into place. Why was that?

Before we put an MSF programme into place there are certain things that we have to be very sure about. MSF has to be impartial and neutral. Its not our business to take sides or make judgements about who does what to who. If you’re going to offer a mental health program in a camp like Jenin with its complex historical political and military fractions, we have to have the trust of all groups and to be seen as impartial. We have to be offering the service to everybody in the camp. So, for instance if we had families that were from one political faction, we equally have to be able to provide the service to families from the other faction. They have to trust us, especially with issues of confidentiality.

Unfortunately if became very difficult to find a neutral and impartial space. Without that, it would have had a serious ripple effect on other MSF programmes in the area. The logical thinking process would be, “Well, MSF only works with that group of people, therefore they’re against the other.” It was very difficult to get some people in Jenin to accept this concept of impartiality and neutrality. It’s not that they don’t understand it in that part of the world, it’s that they’re impatient with the concept. Both sides are.

Why are people so impatient with the concept of impartiality?

I think some people are weary, perhaps have lost faith. The Middle East conflict has gone on for so long, with so much violence, and the idea that you can be there for everybody is very difficult – and for obvious political reasons. It’s especially essential that MSF is seen to be offering a medical service to the people who need it, and that we are not part of the politics there. If we can’t offer that, then that leaves a very serious question mark; that was one of the reasons that the project became stuck. We cannot be “contracted” by one side or another; one group or another.

The second reason that made it difficult to put the program into place was the integrity and security of the program. We have to think about the safety both of the project’s staff and also, very importantly, its potential beneficiaries. People have to believe in and respect medical confidentiality.

What is the current state of mental health services in Palestine?

The Occupied Territories is not like some parts of the world where we go, where there’s absolutely nothing in terms of mental health support, where psychiatry doesn’t exist as a concept. This is totally different on the West Bank. From the West Bank there are many Palestinians who travel, who have trained as doctors overseas. There are many Israelis who would like to offer support and offer very professional psychiatric services and psychosocial programmes in conjunction with the Palestinian Ministry of Health, but the problem is that people cannot travel freely. So, you cannot have an Israeli providing support and assistance, because they can’t get onto the West Bank and Gaza. Likewise, a Palestinian may have been extremely well trained as a psychiatrist, psychologist or psychotherapist overseas, but it’s difficult for them to get back to the West Bank.

The Palestinian Ministry of Health have some psychiatrists and counsellors; what’s missing is the clinical psychologists and psychotherapists for the more complex cases. International organizations are training and supporting, but it’s a slow process given the huge need. You have a counsellor, who can provide basic support and you have a psychiatrist who can treat mental illness, but what do you do with an entire population that has experienced years of conflict, and where nearly everybody has been touched by the difficulties?

What do you do to help people in this situation?

What we do in the field is often about building on peoples’ resilience and their coping mechanisms. It’s really about being able to listen, and to hear the pain, the anger and the distress. Perhaps also what’s important is that an outsider can hear that. Somebody from outside of that normalised process of violence. We work in a very collaborative way with people and say, “Possibly, things are not going to change. How do you live with it? How do you survive it? What are your coping mechanisms?” How does a person get through the day when another person doesn’t get through the day? So, it’s not about curing or fixing people. A lot of the time it’s about supporting people to survive, and to survive in a way that their lives have meaning.

So how do people cope and survive?

I think that this is one of the most interesting and challenging things about working for MSF. A coping mechanism here might bear no resemblance to a coping mechanisms in another country. The whole essence of supporting people is to ask them, “What works for you? When these things happen, how do you cope?” In a society that’s totally different from ours, with totally different concepts, totally different religion, what are the coping mechanisms, both individually and in groups?

People have this expectation that the therapist is coming in with some sort of happy pill. But there’s no pill that’s ever going to take away death, loss, displacement. Yes, obviously we use antidepressants, in a very short term way for the more extreme cases. But you can’t put half a camp with 10,000 people in it on antidepressants. Generally it’s about using talking therapies and being supportive to people, helping people start to communicate, too breakthrough the isolation built up perhaps through stigmatization, shame and fear.

Interestingly though, this idea that there’s a pill – once we’ve started to work with people, I find that they don’t want the pill in the end. It’s about working with them to find ways of survival, and they become quite proud. It’s a coping mechanism in itself that they begin to think, “I can actually see how I’ve survived.” It can be very small steps at times though. I can remember somebody saying to me in Afghanistan, “Okay, it’s not about giving us the fish, you’re going to teach us how to get the fish ourselves.”

Anyone wishing to find out more about MSF’s work can go here. Mental health clinicians interested in volunteering for MSF missions can do so here.