Journal Club Presentation

Presenter: Harsiddhi Thakral

Guide: Dr. Manoj K. Pandey

Psychosocial concerns in a context of prolonged political
oppression: Gaza mental health providers’ perceptions
Marwan Diab , Guido Veronese , Yasser Abu Jamei, Rawia Hamam Sally
Saleh, Hasan Zeyada and Ashraf Kagee
About the Journal
• Transcultural Psychiatry 2023, Vol. 60(3) 577–590
• Fully peer-reviewed international journal that publishes original
research and review articles on cultural psychiatry and mental health
• Social and cultural determinants of psychopathology and psychosocial
treatments of mental and behavioural problems

• Impact Factor: 2.5 / 5-Year Impact Factor: 2.8

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Introduction
 Gaza has been under continuous military attack since 1967 and under a strict
militarily enforced blockade since 2006.
• There are significant restrictions on movement in the area as well as limited access to
clean water, health care, and medical services

 Unemployment, lack of educational opportunities, and food insecurity exacerbate

health risks(Giacaman et al., 2009; Mason, 2009)

 Of 1.8 million population, between 160,000 and 360,000 individuals have

experienced mental health problems (OCHA, 2014; UN-OCHA, 2016).
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What is happening in Gaza right now?

Israel Gaza West Bank

Killed Killed Killed
1139 19,453 (7729 301 (72 children)
children)
Injured Injured Injured
8730 52,286 (8663 3365
children)
Over 8000 missing
73 journalists
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What is happening in Gaza right now?
• Oct 7: Hamas launches rockets, armed attack on foot
• Oct 8: Netanyahu announces ‘multi-pronged’ attack on Hamas
• Since Oct 8:
• Media blackout in Gaza
• Blocking of all connection/telephonic services
• Blocking of food, fuel, electricity, water (siege, starvation, collective punishment, genocide)
• Attack on all major hospitals, mosques, schools, refugee camps, residential buildings
• Death of several premature babies due to NICU failure
• Violation of 4 day ‘humanitarian pause’
• ‘leaflets’ with instructions droppeda
• Bombing of ‘safe shelters’ designated by Israel
• Numbering, detainment, torture and execution of Palestinian refugees waving white cloth
• Bulldozing of people outside the hospital, detainment of doctors
• Naval strikes
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Introduction

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Review of Literature
 High levels of psychosocial distress, including mood disturbance, feelings of
hopelessness, and suicidal thoughts among residents (Elessi et al., 2019)

 Local idioms such as feeling “broken,” “crushed,” “shaken up,” “destroyed,”

“exhausted,” and “tired” (Barber et al., 2016a, p. 7)

 Gazan children have expressed fear of losing their homes and close family
members and experience considerable separation anxiety (Diab, 2018; Qouta &
El-Sarraj, 2004).

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Aim
 The aim of the study was to determine the perspectives of mental health
providers regarding the concerns of their clients.

 Exploration of the specific features of individual and collective suffering and

their political correlates in a context characterized by ongoing military violence
and low intensity warfare (see also Afana et al., 2020; Giacaman, 2018).

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Methods- Participants
Thirty mental health providers, 20 male and 10 female, were recruited for the study
o Nine psychiatrists who were Directors of the centers

o 21 members of multidisciplinary teams consisting of

 social workers (n=3)

 psychiatric nurses (n=9)

 and psychologists (n=9)

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Methods- Participants
• Average age of the participants was 42 years

• Average of 21.5 years of experience in the field of mental health and psychosocial
services

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Methods- Participants
Sample collected from
o One hospital

o Six governmental community centers from the Ministry of Health

o Three specialist centers of the Gaza Community Mental Health Programme

(GCMHP). Selection done on the bases of

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Methods- Participants
Inclusion:

• Collection of data from all geographic locations of the Gaza strip (North, Gaza
city, Middle area, Khanyonis, and Rafah)

• Presence of a psychiatrist as acting director of each center

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Methods- Participants
Exclusion: Community centers that did not offer psychiatric services and were not
registered at the Ministry of Health and the Ministry of Interior as specialized
services for community mental health were excluded from this study

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Methods- Participants
 Inclusion Criteria
o years of experience as mental health professionals (more than three years

o diversified areas of expertise (psychiatrists, psychologists, psychiatric nurses,

and social workers).

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Methods- Participants
 Exclusion Criteria
o volunteers, internship students, nonspecialized mental health workers, and
those working in the centers for less than three years.

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Methods- Instruments
 Semi-structured interviews were conducted in Arabic by five trained researchers.

 Examples of interview questions included: “What kind of clients do you see?,”

“What are the main problems that your clients come to see you for?,” “What are
the main mental health problems that people in Gaza have?,” and “How do you
think the blockade on Gaza affects people living in the Strip?”

 Duration of 35 minutes

 Data collection from Feb to May 2018

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Methods- Ethics
 The study received approval from the Ethics Committee of Stellenbosch
University (protocol number REC-2017-0371)

 Approved by the local Helsinki committee, an ethical board governed by the

Ministry of Health in Gaza (protocol number MOH-1-2017) and affiliated with
the Palestinian Health Council.

 Informed Consent

 Participants informed about rights

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Data Analysis
 Interviews were audio-recorded, transcribed, translated into English by two local
bilingual researchers, and uploaded into Atlas.ti (version 8) software for data
management and analysis

 Data-driven thematic analysis (Braun & Clarke, 2006; Jack et al., 2018)

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Data Analysis
 Two experienced international researchers (GV & AK) and authors of this article
read the first few transcripts, developed a coding system, and created a codebook

 A list of codes and themes was generated using open coding and selective axial
coding that were contrasted and compared

 The codebook was discussed among the research team to identify any cultural
biases. 20
 Data Analysis
 Two locally trained independent coders who are co-authors of this article coded
the rest of the interviews using the codebook as a template. When discrepancies
occurred, they were resolved by means of discussion and consensus building.

 The coded materials were then discussed with a senior researcher.

 Themes and subthemes were constructed by the research team (Boyatzis, 1998;
Glaser & Strauss, 1967) and the results were finalized based on continuous
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dialogue and consensus-building among team members.
Results

Impact of the
blockade on MH
and QoL

Concerns about Concerns about Concerns related

social problems Concerns about
MH of to children’s
QoL
community health

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 The impact of the blockade on mental health and quality
of life of clients
• Makhnogeen (feeling suffocated), Masjoneen (feeling imprisoned), and
Maazoleen (being segregated).

• sadma refers to sudden shocks (Faji’a) or tragedy, such as a major loss and as a
severe, long-lasting traumatic event (Afana et al., 2010).

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 The impact of the blockade on mental health and quality
of life of clients
• Musiba (calamity) refers to a loss with long-term consequences and is seen as
testing a person’s endurance and ability to handle adversity (Afana et al., 2010).

• Ungar (2008) found that youth did not use ‘I’ when they referred to their identity,
but defined themselves through the pronoun ‘we’, reflecting a communal identity

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Micro level
 Segregated and abandoned

 Expressions of suffocation

people cannot escape to look for opportunities. It is like a big prison. They cannot
get in or out..

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Meso level
 Disruption of daily routines

 Environmental contamination

“the blockade affects the situation in Gaza in very hard ways, as it encountered
many levels, health, education, food and electricity.”

the blockade affects all facets of life including the physical environment. Pollution
and contamination are spreading within the community.”
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Macro level
 Change in religious and social values

some people avoid mosques to reduce interacting with others as much as possible …
the religious affiliations and moral behaviours were negatively affected”

“the blockade added another blockade on people’s mentality, people mainly

react by anxiety and fear. The internal political divisions meant that the right
of expression was curtailed by the government. Many people were
imprisoned due to their political opinions.” 27
Concerns about Social Problems
• Laween Rayheen (where are we heading to?)

• Tayheen (we are lost), Maswoohen (feeling drowsy)

• Fesh Amal (there is no hope) to convey a sense of uncertainty and of being

depleted of resources.

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Micro level
 Sense of loss, hopelessness and despair due to unclear future

 Madghoteen (feeling pressured), Khayfeen (feeling scared), and Galganeen

(feeling worried)

““we feel that people have lost positive energy and they [clients] are not motivated
to participate in social activities and cannot look after one another. Also, people
have no savings and are anxious about their future.”.

“people are anxious about what might happen in the future, they do not know what
is happening and nothing is clear.” 29
Meso level
• Impaired sense of community, social cohesion, and support

• Loss of social relations

“there is an extensive fear and anxiety about the future, anger at authority, ‘fawda’
(chaos), limited social visits, repressions, fear in general, and loss of social and
human values.”

“people become aggressive, anxious and social relations are not like before.
Aggression in the community [has] increased and social relations [have]
deteriorated which has led to an increase in hopelessness among people.” 30
Meso level
• Exacerbation by limited healthcare resources

“lack of medications affect people as we follow the medications distribution policy

and we tend to provide people with minimal amounts. The people don’t have money
to pay for the medications; they don’t have money to come to the clinic.”

“relapse rates have increased, and this has resulted in disturbances in

management plans and a poor quality of service. 31
Macro level
• Military attacks, the killing of demonstrators against the occupation, and the
blockade in general have resulted in additional societal emergencies that
undermine the overall wellbeing of Gazan society

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 Macro level
There is a shortage and inconsistency in medication and clients suffer more. Also, the
quality of professional services is limited, resulting in low quantity and quality services”

“due to the blockade we do not have enough medications, we cannot provide medication
for all cases, clients are not able to buy them which will lead them to a major setback.”

“We feel that social relations are weaker than before, and it is difficult to help others
when you need help. We feel that our energy levels are exhausted.” 33
Economic Concerns and Quality of Life
Military attacks, the killing of demonstrators against the occupation, and the
blockade in general have resulted in

• Jehanam (hell)

• Sejen keber (big prison) were used to describe the deterioration in quality of life
of the Gazan people.

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Micro Level
• Unemployed youth

“people cannot complete their studies due to economic hardship. Also, poverty
represents an environment [in which] to develop mental health problems. I believe
that poverty is the worst violence against humankind and economic conditions
influence all social conditions of people. This leads to development of traumas”

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Micro Level
• Unemployed youth

there are no jobs and quality of life has deteriorated as the rate of unemployment
and poverty increased. We can see begging in the streets is spreading, which causes
the increased rate of mental health problems, including an increase in suicidal
behavior and addiction rates.

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Micro Level
• Unemployed youth

there are no jobs and quality of life has deteriorated as the rate of unemployment
and poverty increased. We can see begging in the streets is spreading, which causes
the increased rate of mental health problems, including an increase in suicidal
behavior and addiction rates.

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Micro Level
• Increased cases of suicidal behaviour and addiction to poverty

“suicide appears in the community, aggression has increased, and social

relations are disrupted.”

hopelessness [has] increased among people and this may lead to development of
depression in addition to an increase rate of substance abuse.”

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Micro Level
Increased Family Violence

“Family conflicts have erupted due to unemployment and poverty. Husbands

have become aggressive, they hit their wives and children.”

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 Meso Level
• Disruption of family and social ties

social relations deteriorate, and there are changes in social and recreational
priorities due to economic hardships. The family as a system of support for its
members within the Palestinian community is burdened and weakened due to the
ongoing stress

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Meso level
 Disruption of traditional parental and family roles

 Forced displacement and a loss of community

“there has been an increase in social problems such as couple conflicts and
domestic violence, and analgesia use has increased, and this has led to substance
abuse and addiction.”

“you can see a collapsing community, fatigue, hopelessness, helplessness, loss of

positive energy.” 41
Concerns about Mental Health
• Inhyar” (collapse)

• “Mostanzafeen” (exhausted)

• “Garfaneen” (feeling disgusted and fed-up)

• “Izzhegna men HalWadee” (“we are sick and tired of this situation”).

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Micro level
 Increasing MH disorders among children and women

“PTSD, panic attacks and conversion disorders, and obsessive compulsive disorders
are common. There is an increased number of cases due to difficult conditions, and
malingering cases to get reports from social welfare.”

“Addiction is increasing in the community in order to overcome the consequences of

stress and blockade. Depression exists also as a result of the hard conditions.”
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Macro level
 Economic status and Mental Health

“the economic status has many effects on an individual’s life. As there is economic
hardship, no basic needs and no entertainment, the people become anxious. This
increases the social conflicts, violence, and relation problems.”

“the hard situation causes the increased rate of mental health disorders, suicide,
and addiction in the community—which is new in Palestinian culture.”
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Concerns about Childrens’ MH
Micro level

• Management of traumatized children is a challenge because they cannot change

the root cause.

• Externalising issues

“PTSD is widely common among children because of the unpleasant situation. I

face problems in dealing with them as the trauma is continuous and I don’t have a
role in changing it.”

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Concerns about Childrens’ MH
Micro level

• Management of traumatized children is a challenge because they cannot change

the root cause.

• Externalising issues

“conduct problems have become more common and increased the aggression and
violence rate in schools.”

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Meso level
• Normalization of violence

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Discussion
 Chronic and historical trauma affecting Gazan society at large was seen to
compromise the mental health of Gazans at the individual, familial, and
community levels (Atallah, 2017; Barber et al., 2016a)

 In contrast to Palestine, idioms of distress mentioned by authors who studied

populations affected by war and political violence in other Arab contexts did not
reflect feelings of suffocation and closure (El-Shaarawi, 2012; Hassan et al.,
2015; Nasir et al., 2018)

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Discussion
 The severe deterioration of social capital, community fragmentation, and
disintegration due to physical and psychological barriers diminish and
impoverish people’s sense of belonging and collective resilience (Afana et al.,
2010).

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Discussion
 Feelings of alienation and depression due to the ongoing military violence in
Gaza prevail at the individual and collective levels (Barber et al., 2016c).

 the experience of being trapped in an open-air prison, chronic uncertainty, and a

lack of hope for the future increase the risks for developing psychological
disorders (Rabaia et al., 2018).

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Discussion
 Despite Gazans’ attempts to emotionally and psychologically adjust to the
hardships through resilience and survival skills (Afana et al., 2020; Nguyen-
Gillham et al., 2008; Veronese & Barola, 2018), their powerlessness,
hopelessness, and chronic collective psycho-social suffering persist (Elessi et al.,
2019).

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Limitations
 The interviews were conducted using purposive sampling

 Some of the interviewers of this study reside in the same communities as the
interviewees

 some of the participants are ex-trainees of the authors of this study, which may
have biased the quality of the data.

 living in Gaza makes the experience of mental health providers similar to that of
their clients
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Critical Analyses

Strengths
• Under-researched community
• Use of local idioms, cultural fidelity
• Theoretical themes
Limitation
• Richness of data lacking
• Structure not appropriate across
themes
• Member check and other ethics
• Some quotes not relevant to themes

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References
Diab M, Veronese G, Abu Jamei Y, Hamam R, Saleh S, Zeyada H, Kagee A.
Psychosocial concerns in a context of prolonged political oppression: Gaza
mental health providers' perceptions. Transcult Psychiatry. 2023 Jun;60(3):577-
590. doi: 10.1177/13634615211062968. Epub 2022 Jan 5. PMID: 34986045

Stanger, Nick. (2011). Moving “eco” back into socio-ecological models: A proposal
to reorient ecological literacy into human developmental models and school
systems. Human Ecology Review. 18. 167-173.

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