Palestine’s head of mental health services says PTSD is a western concept

Dr Samah Jabr at her office in the west bank
Dr Samah Jabr at her office in the west bank
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Palestine has some of the highest rates of mental illness in the world. A quarter of Palestinian adolescents have made suicide attempts; about 23.2% have post-traumatic stress disorder (according to a survey of 1,369 over three years) compared to around 6-9% in the US; and the Palestinian territories have by far the highest levels of depression in the Eastern Mediterranean region. Samah Jabr, chair of the mental health unit at the Palestinian Ministry of Health and one of just 32 psychiatrists in the Palestinian territories, doubts those statistics.

“I question the methodology. I think they’re measuring social psychological pain and social suffering, and they’re saying this is depression,” she says. “What is sick, the context or the person? In Palestine, we see many people whose symptoms—unusual emotional reaction or a behaviors—are a normal reaction to a pathogenic context.” There are many people in Palestine who are suffering. But Western-developed tools for measuring depression, such as the Beck inventory, do not tend to distinguish between justified misery and clinical depression.

Similarly, she says, clinical definitions of post-traumatic stress disorder do not apply to the experiences of Palestinians. “PTSD better describes the experiences of an American soldier who goes to Iraq to bomb and go back to the safety of the United States. He’s having nightmares and fears related to the battlefield and his fears are imaginary. Whereas for a Palestinian in Gaza whose home was bombarded, the threat of having another bombardment is a very real one. It’s not imaginary,” says Jabr. “There is no ‘post’ because the trauma is repetitive and ongoing and continuous. I think we need to be authentic about our experiences and not to try to impose on ourselves experiences that are not ours.”

Jabr, author of the book Derrière les fronts (“Behind the Frontlines”) on mental health in Palestine, talks about PTSD in international forums, so as to communicate the suffering of those in her country in terms that can be easily interpreted around the world. But, she says, the condition does not fully capture the traumatic reactions of Palestinians.

“We describe our psychological experience in terms that we hope to be understood in the West, so we talk a lot about PTSD,” she says. “But I see patients with PTSD after a car accident. Not after imprisonment, not after bombardment or being labeled as a person against the law and having a relationship with prison like revolving door. The effect is more profound. It changes the personality, it changes the belief system, and it doesn’t look like PTSD.”

Jabr says people in Palestine who face continual trauma are more susceptible to shifts in personality, and express a variety of symptoms where their emotions stress is manifest in physical reactions. For example, she had a patient who suffered from breathlessness and who was sent to a psychiatrist after physical examinations could not find a cause. “A few months after he developed enough trust, he told me that he developed these symptoms after he was attacked by soldiers who forced him to use filthy words against his wife [and] his mother,” she says. “He was so ashamed of the event, that he had to comply with the instructions or soldiers…and his body expressed the suffering. We see that very often.”

Those living in Palestine endure ongoing trauma. Someone who has their house demolished by the Israeli government in East Jerusalem, because it was deemed illegal, must then pay fines to the Israeli government for failing to destroy their homes themselves. (Nearly every Palestinian building is deemed illegal by Israeli authorities.) Up to 40% of Palestinian men have spent time in prison, often for minor offenses such as throwing stones. And many families face the threat of Israeli-army raids and interrogations.

There are far too few mental health professionals in Palestine to meet the needs of the population, with just 32 psychiatrists for 4.8 million people. Jabr has trained hundreds of doctors and nurses in identifying and responding to mental illness and herself sees up to 30 patients a day. In addition, it’s “not easy” she says, being a senior woman in a government overwhelmingly dominated by men, and she faces a lot of ambivalence from her colleagues about her efforts to address mental health.

In the face of chronic conflict, Jabr says she has come up with her own measures of what constitutes good mental health in Palestine: “To be able to have critical thinking, to maintain your capacity to empathize.” She’s not denying other symptoms of trauma or stress used in alternative definitions, but her primary goal in working with patients is to help cultivate these two mental faculties. It’s important to develop your own mental health standards, she says. “It’s not just the definition of the World Health Organization.”