No Place for Grief. Lotte Buch Segal
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altered in scope and focus since the second Intifada in 2000–2003. The orientation of international donations has shifted from providing medical assistance to people who were wounded in direct violent clashes, during the first Intifada from 1987 to 1993, to the broader, allinclusive category of conducting psychosocial interventions with the people affected by, for instance, house demolitions, violent clashes, home invasions, and the loss, wounding, or death of family members. Rather than following the precise diagnostic criteria for evaluating a client’s mental state, interventions and representations of suffering slide into a witnessing of the general situation of the Palestinians. Fassin and Rechtman term this phenomenon “humanitarian psychiatry” (209).
Against this backdrop, Fassin and Rechtman suggest that a focus on direct violence and the events that cause traumatization have been replaced by an emphasis on the clinical narratives of clients, their general life circumstances, and mundane suffering (2009: 201). While their analysis brings to the fore central tendencies in how adversity is understood in the occupied territories, I would argue that the notion of “event” has in fact retained its centrality. As will become clear in the ethnography that follows, “event” serves as a marker for suffering across diagnoses, narratives, and representations, even when the suffering is not related to an actual event. This was brought to light early in my fieldwork: When I asked the staff in the Prisoners’ Support Center to meet those among their clients who were wives of prisoners, the therapists instead urged me to meet with widows and mothers whose relatives had been martyred and who were therefore able to express their experiences in terms of “events.”
The lure of violent events as markers for suffering emerges clearly in the Prisoners’ Support Center, where documentation of the physical consequences of torture and detention occurs in tandem with the psychological diagnosis and treatment of ailments. Since the early 1990s, in similar zones of protracted conflict across the world, emphasis on the psychological effects of violence has perpetuated psychosocial theories and practices of alleviating the effects of violence (Fassin 2008; Pupavac 2001; Summerfield 1999). As an employee of a Swiss development organization said about the omnipresence of psychosocial intervention; “Is it not what we all do these days?”
One expression of this “empire of trauma” is the sheer number of scientific articles, studies, and statistics, written and collected by both Palestinian and international scientists, about the prevalence of traumatic events and posttraumatic stress disorder (PTSD) among Palestinians (Peltonen et al. 2010; Abu Hein et al. 1993; Salo et al. 2005). In the main office of the therapists at the Prisoners’ Support Center, a faded photocopy on the wall displayed the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) checklists for PTSD, anxiety, obsessive compulsive disorder, and depression—which is remarkable, given that none among the staff were clinical psychologists or psychiatrists. The presence of the DSM-IV photocopy next to ads for favorite takeout restaurants and Naje al Ali’s iconic drawing of Handala encapsulates how therapists imagine their clients’ suffering: it is about a violent event that is direct and detectable through psychiatric diagnosis, despite the fact that the aim of the interventions and the mandate of the organization were more along the lines of local support to prisoners and their families. In a similar vein, the former director of a major health NGO, Dr. Issa Nejmeh, told me how the trope of traumatization was a mode of imagining the plight of the Palestinians and the mental effects on the wounded victims of the first Intifada from 1987 to 1993: “The notion of trauma was related to the people injured in the Intifada, and is completely different from what was later called PTSD. It was a direct physical pressure or manifestation, say, if a resistant lost an eye or ended up in a wheelchair. It was a psychological phenomenon related to a physical happening. Secondly, people became aware of physical problems that were a result of psychological problems.”Nejmeh’s drawing attention to how PTSD in Palestine was related at its inception to a physical phenomenon indicates that the move from physical injuries to psychological distress was circular rather than linear. PTSD was crystallized as a mode of presenting the suffering of the Palestinians (and those in other conflict zones around the world) as on par with human rights violations (see Young 1995; Fassin 2008; Allen 2012), to both the political world and to “eager, but uncaring donors,” as Nejmeh said dryly. Elaborating on the counterintuitive lack of care among international institutions and organizations that channeled large amounts of funding to the Palestinians, Nejmeh offered the well-known fact that, whereas projects concerned with the effect of the conflict are sure to attract generous funds, the political will to change “the situation” have evaporated with what he saw as the post-Oslo depoliticized relationship between Palestinians and their donors.
During our conversation, which started in his clinic in 2007, continued in his living room, and was taken up again in a Bethlehem café in 2011, he elaborated his point by analyzing the main Palestinian actors who work under the umbrella of trauma and psychosocial interventions as a response to violence. These were centers established to help those perceived to have been most severely afflicted by the occupation, namely, the detainees, the torture survivors, or those suffering from physical disability caused by what are considered heroic acts of resistance. It is violence, and thus events of radical negative change, rather than general health, that preoccupies all these local institutions.
Western donors and experts, and their financial aid and knowledge, have been instrumental, though not exclusively so, in shaping how the Palestinian psychosocial organizations have grown, and have set the benchmarks in the Middle East and internationally (Hanafi and Tabar 2005). Though the Psychosocial Bill was pushed by the Ministry of Health in 2009, there is little doubt as to where the best counselors go: to the generously funded NGOs. Therefore the Ministry of Health looks to them, as well as the World Health Organization in Palestine, when it wants to establish so-called best practices.
The infrastructure of psychological care in Palestine is thus remarkably different than elsewhere in the Levant or the Middle East in general. There is most certainly a space for the local sheikhs in offering assistance to the distressed, at least in the countryside and in the more conservative parts of the West Bank and Gaza. But such traditional healers arguably play a less significant role than, for example, in the contemporary Egypt that Amira Mittermaier and Paola Abenante describe in their powerful work (Mittermaier 2011, 2014; Abenante 2012). In Palestine, there is a general familiarity with Western psychology due to Palestine’s colonial past and the ways that European and American concern about the Palestinian plight has been expressed in psychosocial interventions for a traumatized population. Consequently, there is a receptivity, however minimal, to understanding the effects on the psyche that the military occupation may have had. One might go so far as to say that psychology, counseling, and psychiatry have become close to household terms due to the massive effort to raise awareness about the psychological consequences of violence. The largest effort was spearheaded by the late Palestinian psychiatrist Eyad al-Sarraj, whose Gaza Community Mental Health Program has educated and provided services to many a Gazan since the 1990s (Fischer 2007; Perdigon 2011). More than any other, Sarraj’s approach embodies Fassin’s notion of a humanitarian psychiatry, and his approach to the effects of the occupation on Palestinians has been tremendously significant in terms of how the language of trauma, like that of human rights, has become the language of Palestinian victimhood (Allen 2012).
Organizations with a psychosocial mandate thus employ an ever-growing number of the educated Palestinian middle class of health professionals. Nejmeh nonetheless pointed out that indicative of these professionals is “a lack of human resources: we don’t have psychiatrists. Instead we have people who study psychology and then they act as psychological consultants. And we have social workers who have had some training in psychology and sociological behavior.” Whereas therapists have earned BAs in psychology and education, generally from Birzeit University, specialized training is given within the NGOs. These courses are funded and negotiated by the centers’ donors. As the research coordinator of the Prisoners’ Support Center told me, “We follow the fashion. We might want a course in family therapy, but in Europe or the US, EMDR or CBT is on everybody’s lips and thus on the list of training courses that, for example, the EU want[s] to fund because it is evidence based.” The bulk of Palestinian therapists I spoke to described their therapeutic approaches as eclectic, comprehensive psychosocial programs that take into consideration the entire human being and his or her lifeworld. However, access to the treatment and services offered