It is a grey, rainy, foggy day, but I first need to describe the view from the lovely apartment where I am staying in Al Bireh, an area just east of Ramallah, encroached upon by the thriving Jewish settlement of Psagot. When the sun rises the terraced hills light up and I drink in the rocky landscape, the multilayers of ancient stone walls, the stark beauty of the place. But because this is occupied Palestine, nothing is quite that simple. Directly below my gaze is a grove of silver leaved olive trees that end at a road which is accessible by Palestinians. On my left across the road, Palestinian apartments, three to four stories high, rise up on the hill, distinguished by the black water towers that cluster on roofs, (water not being a reliable commodity around here). On my right just across from the olive trees, I note a grey Israeli guard tower draped in camouflage netting sitting beside a water treatment plant for the people of Al Bireh. (news flash: a brief bit of research reveals that the settlement above dumps its waste water on the surrounding Palestinian land, so the PA has taken to collecting their shit (forgive me), processing it at no cost, and then these settler folks grab the clean water as their own on the other end. What can the locals possibly have against these settlers anyway?) Just beyond that major metaphor is a modern, well paved settler road, (no Palestinians allowed), that snakes up the hill to Psagot. So most of land that I am swooning over has been claimed by the State of Israel, the famous “facts on the ground.” At the top of the hill I spot rows of red roofed homes for lucky subsidized Jewish families, a guard tower, and on the crest further to the right, a caravan, the malignant vanguard of settler expansion. Suddenly the view (that this Palestinian family sees every morning over coffee and hard boiled eggs and za’atar dipped in olive oil and that weird processed meat that I cannot seem to get used to), is plagued by risk and loss.
Jewish settlement of Psagot on crest of hill
Psagot, caravan extending the boundaries of the Jewish settlement
Israeli guard tower and water treatment plant
Today I am visiting Dr. Mahmud Sehwail, psychiatrist and founder of the Treatment and Rehabilitation Center for Victims of Torture (TRC). He has that calm and gentle manner that I associate with the wisdom and patience that comes from decades of careful listening and empathy. He explains, “The idea came out of my professional experience as a consultant psychiatrist working at a mental hospital in Bethlehem.” Starting in 1983, he began treating ex-prisoners from Israeli and Palestinian jails and became aware of a huge demand. “25% of the population of Palestine has been arrested at least once, 40% of males. We noticed torture everywhere. We noticed that 40% of those tortured suffered posttraumatic stress disorder (PTSD). According to Israel human rights organizations, 85% of Palestinian prisoners in Israeli jails are tortured; according to our surveys, more than 94% of Palestinian prisoners in Israeli jails.” Whatever the exact percentage, the numbers and the level of suffering is indeed staggering.
He continues, “Victims are reluctant to seek services due to the stigma attached to mental illness. The environment of these services reminds them of the original trauma. Some of them he transferred from prison to a mental hospital said, ‘I would prefer to go back to prison than stay in mental hospital.’” Public hospitals were ill equipped to deal with the level of need. “Victims cannot afford the private sector, there are very few psychiatrists in this country and there is a need for multidisciplinary teams…In 1997 the center was established as an NGO, and we established a board of directors, Dr. Haider Shafi, and Dr. Eyad el Saraj, [late founder of the Gaza Community Mental Health Program]. The first funds were from a Danish institution, and others, we started alone with Dr. Haider and a social worker. The first victim we received was a lady subject to torture by Palestinian security forces, a lady from Ramallah.”
Dr. Sehwail takes out a patient folder to demonstrate. “About our activities and the treatment, we have a file for every client, a TRC case file with demographic details, psychosocial information, domestic violence arrests, psychological testing for monitoring progress of the case, mental status exam, diagnosis category, DSM 4 now 5. The kind of approach for treatment: cognitive, EMDR, and other services, and then the PTSD symptoms. We have a special form for victims of torture in Israeli prisons, we keep data base, types of torture, psychological consequences on individuals and families and another form for Palestinian prisons.” He shifts through the various forms and files and explains, “We receive here patients, clients, our target is ex-detainees, and organized violence. Mainly bereaved families, children and women are majority of clients, ie., the families of the men.” He explains that they treat anyone, “victim or victimizer, for example we treated an Israeli lady married to a Palestinian ex-detainee tortured by Israelis. We received for example a North American tortured by the FBI who was lecturing in Jenin at the American Arab University.” He lists other American citizens who have been tortured, Germans, “a Spanish lady whose son was killed by PA, an Egyptian lady, Palestinians tortured in other Arab countries.” It seems that everybody is doing it.
“We use mainly cognitive, behavioral, group, EMDR, psycho-drama, narrative therapy, and medications. The client is seen by a psychiatrist or general practitioner, some clients suffer from depressive disorder or acute psychosis or anxiety or PTSD so we give medications to reduce symptoms, free of charge. Then the patient is seen by a social worker, by a clinical psychologist and we make an individual plan. The client might benefit from different models of treatment, we monitor progress of the patient, and then make discharge notes and a case summary.” All very 21st century. The cases also get presented to the UN as part of the struggle for human rights and an end to the practice of torture.
But how do you get over something that is not over? “Most of our patients, 80%, suffer from CTSD (continued traumatic stress disorder). Most have multiple trauma, they are victims of torture, arrested by Israelis and tortured, months later they are re-arrested or his brother is killed, so they have multiple traumas, it makes the treatment more difficult.”
“The bulk of our work is the outreach program: 9,000 visits to homes, families are involved in the treatment. They suffer, families or detainees, but the effects on families, economic, social, and psychological consequences, their suffering can be much more than the detainee.” This is the <it-takes-a-village concept> to building mental health and resilience.
They conduct thousands of sessions per year. “There are offices in Ramallah, Jenin, Hebron, the Nablus office closed due to a shortage of funds. We downsized our services, originally 70 employees, now less than 20 due to lack of funds.” (But there is always funding for another smart bomb or prison, but you already know that….)
“We visit victims, families, we have regular prison visits, Israeli or Palestinian. Israeli prisons are not easy to have access. Every time I go to Israeli prison, I say this is the last time, waiting is part of torture. I remember I used to arrive at 8:00 am and you might wait in severe climatic conditions outside for many hours. If they don’t bring the patient or the client at 10:00, I will leave, so I feel guilty, no I will wait until 12, 2, 4, you know, it is part of torture.”
“I have attended several hundreds of military courts to testify, to discuss the medical conditions. You are accused by them, suspected by them, you are enemy. The relations is not the professional, testifying before the court. I remember several times being treated badly.” Equal opportunity torture. He says Palestinian jails are different in their treatment of physician experts.
“We have the training program, we train students coming from different local universities and students of social sciences in mental health and human rights. [The tiny paper cups of bitter coffee and plastic wrapped sweets arrive.] We consider mental health strongly linked with human rights really and we train professionals from governmental and nongovernmental in mental health and human rights. We identify traumatic cases in community intervention, referrals, do more advance courses and we monitor, we do evaluation system for training. We have training for law enforcement agencies. Why? I noticed from some of my clients, you know when I started there was no human rights organization in Bethlehem, Al Haq started in 1983, so I noticed that some of my clients seen by me in prison, tortured their relatives in the same way they were tortured and 60% of Palestinian security forces are ex-detainees and most of them were tortured in Israeli prisons, dynamic of the victim identifies with the victimizer.” I suggest you read that again slowly and consider the immense implications of that statement.
“So I started this training in 1996 in order to prevent human rights abuses. At the beginning many of them were defensive, but now they come to us. One of my cases when he was released, he attempted to kill his fiancé, he interrogated her. He had been jailed for one to two years and when he was released, he interrogated her in the same way he was interrogated. This brought my attention to this. I remember [another] chap was detained by Israelis for one year, a student, and he suffered from severe PTSD, completely detached from reality. When he got married he stayed with his wife, was in winter, outside the room for many hours, naked, both of them, the same way he was tortured by Israelis, naked. Okay, that’s the training for security forces, really now they come to us and sign memorandum with Ministry of Interior Affairs, to train. We have curriculum, case presentations to show the effect, the psychological effect of torture.
“We have summer camps for affected children from ages 10 to17, in groups, not only recreation, more treatment, group therapies, selected from our target group. We have camps in Jenin, Nablus, Ramallah, Hebron, for more than 300 affected children, boys and girls.”
“We have advocacy, we gather for remote areas. We cover women, men, children; we talk about the consequences of torture. When detainees are released, they lost their work, their contact with the community, their personality is destroyed. The aim of torture is to kill the soul, to spread fear in the person, family and community, to change the mind and character. The family is left alone. The wife has to work and to maintain family, kids, and really, the woman in this country is the final recipient of any trauma. So they are, they don’t know the consequences of torture, not aware.” So we talk about that, for example, some victims or ex-detainees isolate themselves.”
“We approach newspapers, TV, media, for instance, the June 2014 conference, [I attended that, see 2014 blogs]. April 17 Palestinian Prisoners’ Day, December 10 Human Rights Day. We invite key persons from the community, big gathering for affected families, bereaved, detainee, ex-detainee families. We organize events in Ramadan, in Ramallah, in Jenin, and other cities. They discuss with key person, with Palestinian legislators, governmental decision makers, they discuss with them their issues. We organize for families groups; we bring sheikhs (open minded sheikhs) and psychologists from our team and they talk about their traumas, how the community doesn’t permit them to talk freely, to vent their anger. We noticed one knows each other and visit each other and form small groups between them, support groups, those who cannot overcome their trauma are treated in our small groups.”
“We have special vocational training, it depends. We organize with the Ministry of Labor to know the needs of each district; for example in Jenin, we subcontract those who train barbers, in Hebron, ceramics and carpenters. They generate money, through treatment and rehabilitation center, hundreds were trained, supported themselves from vocational training and generate money to maintain themselves.” There is also a small research unit that examines mental health and human rights issues, once or twice a year.
Dr. Mahmud Sehwail trained in Spain and Britain with a subspecialty in geriatric psychiatry, but he found that was not needed in Palestine “because we are an extended family. I came back from Spain in 1983. I wanted to come back, at that time I didn’t have an ID. I was from a small town here, grew up here, high school in Ramallah. But the main reason [to return is] I lost my brother, killed by an Israeli at 17. I couldn’t save the life of my brother so I have to save the life of others, Israelis and Palestinians. I passed through big trauma, it took many years to get my ID, a long story, five years to get the ID. I had a contract with a mental hospital here. Now we leave this job to the young people.”
He smiles at the medical student who has accompanied me; the young man explains that medical students are not interested in psychiatry due to the stigma of being a psychiatrist and working with psychiatric patients, but admits that Dr. Sehwail “is really impressive, he is my idol.” I take that as a very good sign.
We move on to more political topics and Dr. Sehwail’s work as a human rights activist. “To change the political, that is not easy to change the environment, Israeli or Palestinian…it is paid occupation. Palestinians pay for the occupation, but the US, Europe, Arabs, (I mean the governments not the people), fund it. It is the last occupation in the world, unfortunately supported by Americans…Palestinians alone cannot do anything, it is not a local responsibility, it is local, international, and regional responsibility. I think what happened in Palestine, in Rwanda or Somalia, it affects everybody in the world, so it is an international responsibility.”
“The last election in Israel, how Netanyahu won the elections? By the extremists, by racist speech. The Israeli community is moving more and more towards extremists and racism. He gave a speech, if I am elected no Palestinian state. The Americans and the west and the Arab countries they have the answer; I am sure they will continue supporting Israel. It is a shame for the Americans, the leading democratic country, applauding for the racism of the occupation, they have lost their values.”
I keep asking if we are taking up too much of this good doctor’s time, but clearly he needs to talk. Perhaps this is his therapy? I ask, what is his vision after occupation. “I think peace for the whole region, and we will be a model for democracy, if justice achieved, peace achieved. Palestinians will build the Arab countries, they have the ability to establish a country. The factional fighting is not an internal issue, it is controlled by outside powers. The PA has to follow Arab countries and the Americans, Hamas has to follow other regional powers, is not an internal issue. I think Hamas will not refuse the peace with Israelis. Peace is an aim for every Palestinian but, I don’t’ expect any progress in the ‘peace process.’” We all agree that it has been dead on arrival for many years.
“Israeli is a sick society, they live with their paranoia of being persecuted. [His phone rings and he takes a call from an agitated patient worried about drug doses.] They change their role from being persecuted to persecutors and I think the history might repeat itself. It is a very harmful state for the Jewish community; we have to differentiate the Jews from the Zionists. What they are doing for the Palestinians, the same did for the Jews. How come the victim becomes the victimizer? They don’t have insight into their paranoia, they were persecuted, even before the Nazis, in Spain you know and Russia and many countries. Jews were persecuted victims. How come they become persecutors and victimizers? I think that is the pathological dilemma. I think Jews everywhere they have to fight with Palestinians, but to give them insight at least what you are doing is harmful for every Jew and for the whole world. It is the other face of the Nazis, they revive the same scenario, it is so. I think it is our message to the Jewish population everywhere is to fight the occupation, to end the occupation and to live in peace, together to fight the ugly face of the Jewish.”
“I remember more than 10 to15 years ago, a journalist from Canada came to me to talk about the dynamic of suicide bombers. I sent her to the outreach program in the north and south to meet with families. After five days, [she reported to him] I am potential suicide bomber, there is no need to explain about the dynamic of the suicide bomber. Okay, it is the created culture of hateness among our generation. The Palestinian child cannot identify with the local authority, with a defeated father, or the family cannot protect itself, so the child has to identify with the Israeli soldier or with the extremist, the strong figure.” And thus a militant resistance fighter is created and the IDF arrests more children and demolishes more homes and…..
I ask him what keeps him going? His eyes twinkle and he smiles, “Continue working, helping others, helping myself. That is the only relief.” At that point a younger administrator arrives to help him sort out his uncooperative computer and they are soon lost in passwords, programs, email, and other tortures of the modern world.
I move to the office of Dr. Haider Shafi, immediately I feel that he is another warm, wise soul and our connection is palpable. He confirms much of what I have already learned. He expands the meaning of families as secondary victims: “wives, children, parents, in relation of the pain of the arrested person, but they are also targeted. When they come to arrest, they surround the house with large number of troops, spread fear and terror in the house and in the local area…all the neighboring houses standing on their nerves expecting something might happen.”
I was unclear as to the meaning of victims of organized violence: “injured in demonstrations, or land was confiscated, or house demolished, also school kids who need to pass through checkpoint and who need to be body searched, it is really so difficult.”
He is particularly concerned with children: “I am always worried about children…those children are in normal way if everything around them is normal. What kind of power those [traumatized] children have to compete with other normal children elsewhere?”
I ask how does he inoculate that child and he sighs, clasping his hands together. “In our work, we look at children according to their age group, what we provide for little kids is different what we provide for late childhood. We develop idea of summer camp, provide crisis intervention, do psychotherapy in an atmosphere that doesn’t make them feel like they are patients. They thrive during the summer camps; we include group therapy, four times per week, that makes 12 sessions during the three week summer camp, as part of their program, we introduce psychodrama. They like it, and they feel released and at ease and amused.
So what is psychodrama? “We normally initiate a group of 12 to15 children well known to TRC clinical team, we create a group and we set some principals, how to be committed, respect each other, confidential. We select someone who would like to act his problem, like not say I have a problem but they will say it is so bad when they arrested my father or when I visited my father in prison first time that I thought I could sit with him, hug him, but I couldn’t touch him. I saw him behind a glass wall, I couldn’t hear properly, time was so limited, it took almost a day to arrive and come back so we spend 12 hours traveling and we couldn’t see him for 45 to 60 minutes. And also some children feel their father’s appearance changed, were cool in dealing with them, (not understanding they cannot do otherwise). They think dad wouldn’t want to see them and they also speak about how life became different because father is longer there and some they miss their dad because if they quarrel in the street or school, they have to solve it themselves or run for mother or cousin. They also speak about how difficult their financial status is, they don’t have other source of income.”
In psychodrama, “two to three kids, they each have two minutes for what they like to say. We ask the audience to stand with the person they have the story they want to work on. So the person who gets the most is elected to speak about his problem. They talk and walk, they act part of it and they also speak about it, they feel debriefed and relieved and they feel good support from their peers. If a child wants to play arrest of his father, he might select someone to play role of father, mother, soldier, to reenact the real event. Then when that is done, he is debriefed, they usually have emotional release and catharsis. He will feel good; if he failed to say goodbye or might feel guilty that he didn’t do enough to keep dad close to them, or feel bad that they did something during the arrest, we make them feel no longer guilty. They didn’t do anything to cause the arrest, we encourage them to say what they want to say to their dad and whatever words they want to say to the soldiers, and others. They usually play the role and they speak about their personal experience during the play, they react according to the instructions of the protagonist, and they reflect on their role. It might trigger some of their previous experience or their current fear and anxiety, or remember the blessing that their dad is there, some victims have been released.”
I ask about the level of physical violence I observe on the street especially when boys are playing. “Physical violence in psychodrama, we don’t let them hit with a real stone, he might use a scarf, symbolic play, symbolic objects, never harmful. Sometimes we attribute children’s fighting and aggression as a reflection of surrounding the aggression. We need to know that children, especially in late childhood before twelve, tough playing including some physical fight with peers and sisters is not uncommon, and to some extent normal unless the harm is beyond childhood norms.”
“We us other treatment: EMDR, [Eye Movement Desensitization and Reprocessing]. I learned it in the US, Francine Shapiro, a Jewish American and wonderful person, founded EMDR in San Francisco. EMDR is a powerful method, at the beginning we thought it is eye movement desensitization, but now tactile, hearing senses as well, can produce similar effect, good for traumatic events. A kind of bilateral stimulation, eye movement desensitization and reprocessing, it is kind of bilateral stimulation of both hemispheres of the brain and this stimulation works against the principals of PTSD and direction of PTSD, in short PTSD shuts the amygdala and EMDR opens up the old memories, traumatic memories and help people to talk more about their bitter experiences in a safe atmosphere while they get enough support and assistance and once they are done they feel much more relief and encouraged to continue with their lives.”
“For children we can use butterfly technique, cross arms across chest like a hug, tapping slower is associated to relaxation and faster to reprocessing. Then they start to talk and then tap, we use other practical techniques in summer camp. Children’s tapping hands and play for each other and we also use narrative. TRC is the most specialized center for narrative therapy, we established the Palestine National Institute of Narrative therapy. You help the persons to narrate his own story but you help him re-author his own. Doing so [there are] many good stories are not remembered and not talked about during a major trauma, but we thicken these small stories and make them form a kind of alternative story, so every time they look at themselves as victim they also discover they are also survivors and warriors. A victim might speak how weak and embarrassing during torture, his experience with inferiority, forced to bark like dogs, or walk on four arms and legs, but we will help him discover how brave he was to stay in solitary confinement, how he could allow his mind to go beyond the walls of the cell, how strong he was to compose some poems, to hold a lot of love and missing for his family, to think of them despite his fear, weakness, and illness, then they discover that the shame most not be allocated in the them but rather it is cardinal issue of the aggressor. So many people speak about escaping in the very last minute, bombed while others they failed so they died. We, for example, work with those people, they were not selfish, they were good citizens, they could save their lives and some around them, despite the fear, they were not cowards. They were able to take the essential measures of security. Despite the fear, they carried milk, medicine, and food for their kids, the mother didn’t forget some sweets or a blanket to cover her children. How strong they were to stay together and not to go out, to tolerate the boredom in a small room for a long time. They could do that because they were responsible, smart, clever, they could protect themselves.”
“So this kind of re-author of stories you need to double listen to what he is saying and to what he is trying to say, the absent but implicit. Like they might not speak about the courage, aspirations they have, but when you look carefully at their acts, their lives today, they discover that the absent is already implicit, they are going towards their goals and aims. We also use CBT (cognitive behavioral therapy) to help people to demonstrate the negative traumatic thoughts and to associate them with dysfunctional beliefs, like sugar with tea,” and ultimately to change established thinking patterns and behavioral activation by focusing on particular problems in the present. He explains that the different methods they use are backed up by evidenced based literature that shows great effectiveness with traumatized populations.
“I want to say a little bit about the entire picture, it is not about children, parents, mothers in isolation. Any society is composed of parents and children under the same ceiling. They share similar concerns. The nature of the Palestinian society is close family members and also children remain children when they are grownups, for example it is not the general picture of children leaving home at 18. They might get married and live with parents; extended family helps in this situation, we do not fear very much loneliness.”
“So sometimes the part of the problem of the father is he has guilt feeling because he left his family members for a long time or he is too poor to achieve for his kids what he was dreaming of when he was in prison and also for the mother, almost the same thing. While she herself is suffering the absence of her husband and kid’s father, she has to resume some of his role socioeconomically and emotionally. Also, she needs to be strong in order to fit these two different roles; so she might not have time for herself to grieve. So we often say that women in our society are the real heroes but they suffer in silence. I personally think that the real strength in Palestinian society comes from women, they are the final recipient of suffering and pain.”
Dr. Haider thanks me, and says I am relaxed, easy to talk to. I get the feeling he is feeling better. Everyone needs to be heard.
My last interview is with Raya Farsakh, clinical psychologist and project manager, a medical student is translating. She is younger, vivacious, and has lots to say. “My work is with people in the field, I go to homes and see them, the majority are ex-prisoners, families of martyrs and people who go on protests and are violated, mainly in refugee camps, especially at wall protests like Nabih Saleh. I see lots of children who are violated at these protests and they need help. I am not only working with victims of torture, but I help the entire family. I am helping the victim and I get better understanding of the victim by understanding the mentality of the family, so I work with victim by working with the family…At the summer camps, not only are they involved in fun activities, but they also teach the children something and to do something to help them cope with what they suffer with group therapy, hand works, painting, teaching first aid skills.”
She explains that there is a “specific group, prisoners for more than10 years. This group is suffering from being away from their families for a long time, so special situation. They do not take part as father or husband, are not accepted, everybody is independent, being back in prison is easier. There are emotional conflicts, for the young group of prisoners, when they get out they want to go back to school and they have to be in class with younger people, so they do not go back. So they learned some skill outside; they do not want to go back and sit next to student years younger than him. So there are many ways to convince them, put a studying schedule, visit school, meet with teachers, to help accept, use cognitive behavioral therapy, use learning in process of treatment.”
“Another difficulty in young teen prisoners, they feel guilty for leaving their families, they want to support the family, bringing money, the majority do not go back to school, they want to be productive.” She cites a specific case in the village of Salfit. [A man was] 24 years in prison, went in at age 24, now 48. But the thing is he sees life as a 24 year old as if time has frozen, a young person trying to explore life, not living his own age. Difficulty for him was he was under a lot of pressure and he didn’t experience life. His family wants him to get married immediately, they don’t want him to be alone, so they are trying to be helpful, but in wrong way. His life was as if was continually in prison, wakes up early, like prison, he is not used to hearing kids playing, he gets irritated and angry if any loud noise, always agitated about these new experiences. There is a strong feeling of guilt for leaving his colleagues in prison, he has betrayed them, wants to call them, is not enjoying life because of this.”
“The patient doesn’t feel himself, doesn’t know that he has weird symptoms to worry about. The whole society is visiting every day…no time to focus on himself. So we meet every prisoner who is freed, so we go talk with him, he does not know that he is not well. The subject is not only interpersonal therapy, he may need medications, [psychiatry or psychology visits], after 18 to 20 sessions how I changed his ideas and thoughts about guilt, about his colleagues, had him communicate with the families of prisoners, explained how to work hard during the day and get sleep at night.” She helped his family understand that he should postpone marriage until he asks for it, she taught him relaxation exercises to deal with his hypervigilance. “Another fact is the Ministry of Prisoners gives life time salaries if someone is in prison for five or more years, so [the prisoner] doesn’t care about making a living. She wants to convince him that he needs to work to feel productive, it is his duty, not just to earn money, he receives 6000 NIS per month. So he is now happily married with two kids, I am satisfied with my own efforts.”
She tells us more stories and I ask if the male prisoners and ex-detainees have trouble seeing a female psychologist? “My duty is to break the ice with the patient so they open up. I don’t have trouble with the majority of case, even if sexual problems, I go step by step, most of the workers are females and majority of prisoners are males so this is normal”
I ask about sexual violence in the prison, or sexual problems outside. “It is not a regular thing to happen, not in the literal meaning of the term. In the prisons, they get physical harmed on specific parts of their bodies so they are worried about dysfunction, because they are mocked, naked in front of soldiers, but usually [sexual attacks] not done by Israelis.” She reassures me that this doesn’t happen between prisoners, not in this culture.
The interview is over, she needs to go back to work, and there is indeed an endless amount or work to be done.