Understanding Palestine’s colonial, intergenerational trauma from a mental health perspective

Dr. Samah Jabr, head of the Mental Health Unit at Palestine’s Ministry of Health talks to The Hindu’sSaumya Kalia about authentically defining and measuring the trauma that Palestinian bodies and minds face. She explains what makes PTSD a Western concept, why clinical mental health systems fail people facing oppressive policies and colonial injustice, and the urgent need to build communal forms of care that address Palestine’s collective trauma.

Updated - November 17, 2023 12:06 am IST

Published - November 16, 2023 11:55 pm IST

The aftermath of after Israeli strikes on Rafah, Gaza Strip on November 15, 2023.

The aftermath of after Israeli strikes on Rafah, Gaza Strip on November 15, 2023. | Photo Credit: AP

In Palestine, trauma does not sit alone with the individual, and it does not lie idle in the past. Millions of people in a densely populated sliver of land are facing a persistent loss of home, land and safety. One out of 200 people has died in Gaza since October 7. Every hour, on average, 42 Israeli bombs fall, 15 people are killed (six of them children), 35 are injured and 12 buildings are levelled, as per United Nations OCHA data. Water, food, fuel and electricity have run out inside hospitals and across the region, triggering an unprecedented humanitarian crisis.

Dr. Samah Jabr, head of the Mental Health Unit at Palestine’s Ministry of Health.

Dr. Samah Jabr, head of the Mental Health Unit at Palestine’s Ministry of Health.

The late Eyad El-Sarraj, founder of the Gaza Community Mental Health Programme, said in 2005 that the psychological effects of Israel’s occupation of Gaza, and of violence in Palestine, have created a “learned helplessness”. The aim is “making the whole population captive to fear and paralysis”.

Dr. Samah Jabr, head of the Mental Health Unit at Palestine’s Ministry of Health talks to The Hindu’sSaumya Kalia about authentically defining and measuring the trauma that Palestinian bodies and minds face.

Studies show post-traumatic stress disorder (PTSD) is among the most commonly recognised psychological disorders among Palestinians. You have previously questioned the methodology of these studies — they measured “social psychological pain and social suffering”. What was the nature of your concerns with this? (for online only, not able to ‘note’ it)

The concern might involve both the methodology and the way trauma is articulated. Studies measuring “social psychological pain and social suffering” might capture the broader societal impact of trauma, but could potentially overlook individual experiences and the complexity of trauma responses. On the other hand, an individualistic approach to trauma might pathologise the individual and fail to provide solutions to the pathologising context

Trauma in the Palestinian context is a complex and deeply layered topic. In my clinical practice, I more often see people affected by a prolonged, enduring collective trauma that changed their world outlook and belief systems as compared to people who suffer from the usual reexperiencing, hypervigilance and avoidance symptoms of PTDS.

You wrote Palestinians often use this phrase to describe their feelings: ‘Badany Masmoum, Maqhour, Mazloum, Maksour Khatry’. I feel that my body is intoxicated, oppressed, exposed to injustice; my desire is broken. What do you see, and hear, from people who have lived under a regime of discrimination and violence for decades?

Palestinians have been exposed to chronic stressors, including grief, displacement, economic hardship, and the ongoing threat of detention. The phrase you mentioned encapsulates a profound sense of physical and emotional distress, and cognitive changes, reflecting an ongoing suffering and psychological impact.. The psychological impact of shattered hopes, dreams, and aspirations; of feeling abandoned and betrayed. It represents the breakdown of personal aspirations and the collective yearning for a peaceful and dignified life amid the persistent conflict. 

Over time, Palestinian expressions of trauma have likely evolved due to prolonged exposure to conflict and oppression. This exposure over generations has not only led to adaptive responses, but also significant psychological distress, which affects their cognitive processes, emotional regulation, and interpersonal relationships. Living under such conditions for an extended period can lead to a range of psychological impacts — heightened anxiety, depression, feeling helpless. Moreover, prolonged exposure to trauma can alter brain development in children and drain functions in adults, impacting memory, attention, and decision-making processes. It can change the personality, identity, the view of self and others.

Can you explain the intergenerational mental health impact of Israel’s policies? The segregation or the chronic underinvestment in infrastructures, how do families process this routine discrimination?

Oppressive policies, displacement, and denial of homes have long-lasting effects on families and generations. The absence of a stable home environment and chronic stressors impact mental health across generations. Trauma will not only affect the attachment between a parent and a child, but also a traumatised parent can pass it on (epigenetics) to the offspring.

There are endless examples of this [intergenerational trauma]. Look at Palestinians’ reaction to all these calls to displace people in Gaza. Because we have a history of displacement and the Nakba, the reaction to images of people being dispossessed from their homes in Gaza is of a continous fear.

Can you explain your criticism of post traumatic stress disorder (PTSD) or the Beck inventory as Western, colonial concepts? What has shaped our understanding of ‘trauma’ and psychological distress today? 

You’re absolutely correct that Western mental health tools and diagnostic criteria, such as those used for PTSD, often fall short of understanding and addressing the experiences of non-Western or marginalised communities. They rely on cultural frameworks, which might not adequately consider the complexities of cultural nuances, historical contexts, and the collective nature of trauma prevalent in societies like Palestine.

In many non-Western cultures, the expression of distress or trauma might differ significantly from what is outlined in standardised diagnostic manuals. For instance, in Palestinian culture, the experience of trauma might be expressed through somatic symptoms, communal storytelling, or religious/spiritual explanations rather than fitting neatly into the symptom categories defined by Western psychiatric criteria. Mental health issues in communities like Palestine are often deeply intertwined with the region’s historical and ongoing political turmoil, such as displacement, occupation, and oppression, affecting entire communities rather than just individuals -- and with this, comes a feeling of normalcy. Western tools may overlook the socio-political influences (which are determinants of mental health), failing to capture the full scope of trauma experienced collectively.

Also, the therapeutic interventions might be inappropriate: suggesting self care for a people facing genocide is not a good idea! In collectivist societies like Palestine, trauma is often shared collectively among families, neighbourhoods, or entire communities. This collective nature of trauma might not align with the individualised focus of Western diagnostic criteria. Traumatic experiences, such as the loss of land, displacement, or witnessing violence against family members, can have far-reaching effects that extend beyond individual psychological symptoms.

Israel is attacking schools and healthcare facilities like Al Shifa Hospital– where patients, civilians, journalists, and aid workers are taking refuge – indiscriminately. How does the brain, the body and the person respond to a continued denial of safety?

A prolonged lack of safety can lead to chronic stress, affecting both the brain and the body. Constant exposure to danger triggers heightened stress responses, impacting mental health and well-being. Usually, stress responses include physiological responses — like shortness of breath, headaches, stomachaches, and numbness in the limbs. It can be any physiological response — somatosensory and aches and pains. 

But it is impossible to provide useful mental health interventions when there is no safe place. [In a letter to The Lancet, Dr. Jabr and Elizabeth Berger of the USA-Palestine Mental Health Network added: “The constant bombardment makes it impossible to find a safe place anywhere and the lack of food, water, fuel, and electricity precludes the meeting of basic human needs. The once-functional mental health system has thus in the past weeks experienced a progressive shrinking of services to the degree that of six public community mental health centres, the lone remaining centre in the south has now closed and has run out of medications...our professional staff, accustomed to the constricted circumstances of the longstanding siege, has now experienced far deeper trauma; therapists often possess nothing but the clothes on their backs and must frequently relocate from one house to another. We must face the reality that we will be unable to rely on local capacity-building to fulfil the psychological needs of the community in Gaza.” Read their full letter here.]

How would you differentiate between ‘individual’ trauma and ‘collective’ trauma? For instance, how would the Western mental health framework slot the psychological impact of Israeli’s airstrikes on Palestinian refugee camps, which have killed hundreds?

Individual trauma pertains to personal experiences, while collective trauma involves shared experiences of a community or group.

The Western mental health framework may not fully address collective trauma, particularly in contexts of systemic violence, displacement, or dispossession, experienced by entire communities. In the Palestinian context, I see many people affected by the killing of their neighbour or classmate. I currently work with Palestinians from Jerusalem and the West Bank, who are affected by witnessing what happens in Gaza. People usually come complaining of depression, panic attacks, or anxiety. When we start talking to them and asking about their life story, then the story of grieving for someone comes up.

A dehumanising narrative accompanies the present war – some Israeli content makers are making TikTok videos mocking Palestinians’ cries of suffering. World leaders have compared them to ‘dogs’. Does this language distort, or normalise, people’s justified misery? 

Dehumanising practices such as humiliation, violation of dignity and autonomy, and forced nudity, when imposed on Palestinians in various contexts, particularly in detention, arrest, or during military operations, have severe and lasting effects, both psychologically and socially. These actions are not only degrading but also violate human rights, exacerbating the trauma experienced by individuals and communities. It can induce severe anxiety, depression, and long-lasting psychological distress among victims.

Stripping individuals of their clothing is a direct attack on personal dignity and autonomy. It serves to humiliate and debase individuals, stripping them of their humanity, and often occurs in public or in front of others, cameras, amplifying the humiliation. Forced nudity can deeply affect an individual’s sense of identity, self-worth, and personal integrity. It can lead to a profound loss of self-esteem and self-respect, contributing to long-term psychological scars. Victims of forced nudity often face societal stigma and shame within their communities due to the humiliation they endured. This stigma can further isolate and marginalise individuals, impacting their relationships and social integration. It can also instil a persistent sense of vulnerability and fear in individuals; their perceptions of safety, particularly in interactions with authorities or in similar contexts, are compromised. In the long run, it can impair recovery and healing.

Frank Chikane in 1986 used the term Continuous traumatic stress (CTS) to explain how South Africa’s Apartheid state impacted children’s mental health. Can you tell us more about CTS?

CTS, similar to PTSD, refers to ongoing, chronic stress due to prolonged exposure to traumatic events. It can manifest in various ways and might be a more suitable framework to understand intergenerational, colonial, and continued violence’s psychological impact. CST finds some place in Palestinian literature, but mental health in Palestine is more layered. There are intricate historical and collective aspects here, in addition to the prolonged and repetitive nature of violence. 

Political philosopher Frantz Fanon argued that we cannot understand psychological problems without understanding the conditions of oppression that lead to them. Why is it important to distinguish between an individual and collective injury?  

Distinguishing between individual and collective injury understands the broader societal impact of trauma and addresses systemic causes, rather than pathologising individuals. Recognising and addressing these multifaceted impacts is crucial in providing individuals and communities with adequate support and interventions.

The ‘We Are All Mary’ campaign powerfully conveyed the experiences of Palestinian women living under oppression, while also working to heal ‘injuries to Palestine’s social fabric’, you noted. What are some conceptions of trauma that can confront intergenerational, enduring damage?

Palestinian culture has its own healing practices and community-based interventions that may not align with conventional Western therapeutic approaches. These could involve religious and nationalistic beliefs, storytelling, glorification of Martyrs, connection to the land (for instance, olive harvesting is like a feast for Palestinians) or community gatherings, which are deeply rooted in the cultural fabric. These practices might not be recognised or integrated into Western mental health frameworks.

Practicioners can focus on sumud (steadfastness), solidarity, redress, resistance, accountability, narratives, storytelling, and community healing, contributing to addressing collective trauma beyond clinical definitions. Such efforts aim to rebuild social fabric, validate experiences, and promote resilience.

In the end, addressing collective trauma requires comprehensive approaches that go beyond clinical models. They need to embrace cultural, historical, and communal healing practices — while acknowledging the systemic injustices perpetuating suffering. We have to empower the Palestinian community to address mental health as a form of resistance against the impact of the occupation on our minds.

An individualised perspective on suffering does injustice to the complex realities of people in Palestine, and Dr. Jabr and Dr. Berger argue that mental health systems must centre forms of care that are collective and communal. The highest priority, however, lies elsewhere: “We must emphasise that the overwhelming need now is not mental health, but ceasefire.”

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