The Psychological Symptoms Profile of the Palestinian: Exposure to Political and Environmental Trauma-Related Stressors

Illegal Occupation has been the experience of the Palestinian people for over 55 years. As the economic and social devastating hardships increase so have the heightened vacuum of psychological problems. The traumatic related stressors which are inflicted on the Palestinian people have developed into a diverse spectrum of inter-related psychological symptoms. However, trying to understand and identify the Palestinian symptoms which are related to their trauma can be very difficult if one does not examine the severity and persistence of these related stressors. This is why it is very crucial that before deepening oneself into what are trauma related symptoms of the Palestinian people, West Bank mental health professionals must first define the meaning of trauma. According to trauma expert, Dr. Horrowitz, 1996, describes trauma as:

	a. The fluctuating nature of acute and/or grief reactions that can lead to complex characterlogical adaptations.
	b. A disturbed regulation of affective arousal that can ward off emotions, somatic sensations and alternating intrusion and numbing feelings about the catastrophic stress and event.
	c. The impaired capacity for cognitive integration of experience (dissociation).
	d. The impairment in the capacity to differentiate relevant from irrelevant information.

For example: Exposure to Human-Made Perpetrated Trauma include:

	· Illegal Statehood Occupation
	. Criminal victimization
	. Physical victimization
	. Sexual victimization
	. Political violence (assassinations, home demolition, military closures, curfews, checkpoints, sporadic military shelling and bombing)
	. Community Violence.
	. Family violence
	. Serious incidental accidents
	. Family violence

Exposure to a Natural Disaster includes:

· Weather catastrophes (earthquakes, major floods, Tsunamis)

Exposure to Life threatening Illness:

	· Chronic Diseases (cancer, diabetes, HIV)
	· Physical Handicap

In addition, it is equally vital to understand what type of emotional or physical trauma did the Palestinian person's experience. Clinically differentiating between whether their exposure to the trauma was related to a human-made perpetrated trauma, natural made trauma or a Life threatening ill is critical to both treating, and improving the overall prognosis of Palestinian people. Therefore, when trying to identify the treatment needs for the Palestinian people, it is clinically critical to understand how the different types of exposure to trauma develop diverse symptomotological reactions. In the Palestinian society, as a result of the Illegal Occupation, West Bank Psychologist have mainly focused on examining the psychological effects of "human made perpetrated trauma". This may include:

	· Witnessing or first hand experiencing the psychological effect of assassinations.
	· Physical brutality.
	· Wounded by bullets.
	· Home demolishment.
	· Military checkpoints.
	· Military curfews.
	· Military closures.
	· Tear gassing.

So when trying to understand and develop the symptom trauma profile of the Palestinian plight, it is clinically critical that the international mental health society take into consideration how 55 years of ongoing Israeli military occupation significantly differs from the typical clinical researched symptom profile of severe trauma. In that, the type of trauma which the Palestinians have been exposed to, is a combination of both human made perpetrated violence and severe natural disaster trauma. The individual and collective exposure that the Palestinians' experienced have not been clinically researched anywhere else in the global world, except during the South African Apartheid in the 20th and 21st century.

When trying to develop a Palestinian symptom profile criteria associated with the traumatic occurrence, psychologist must assess nine categories in order to gain a deeper understanding of the trauma related symptoms.

They are:

	a. Human made perpetrated/inflicted trauma vs Natural disaster vs Life threatening disaster.
	b. Witnessed trauma vs interpersonal experienced trauma.
	c. Collective Vs individual punishment from trauma.
	d. The age-onset of exposure to the trauma.
	e. The age-onset of symptoms.
	f. The gender who was exposed to the trauma.
	g. The duration of trauma (acute vs chronic).
	h. The secondary multiple reminding stressors associated with the trauma.
	i. The social support system exposed to the traumatic experience or to trauma in general.

Unfortunately international clinical studies on the different types of trauma have not been specifically focused towards the Palestinian Psychological Plight.. However, many clinical studies have attempted to understand the interrelationships among different type of trauma related symptoms (Goenjian, Steinberg, Najarian, Fairbanks et el, 2000). Clinical psychologists have examined the longitudinal differential symptomatic effects of witnessed exposure or interpersonally experiencing “human made perpetrated trauma”; while doing a comparative study to either witnessed exposure or interpersonally experiencing a severe “natural catastrophic trauma.” Clinical psychologist have also clinically researched the different symptom profile of early onset exposure versus late onset exposure (Goenjian, Steinberg, Najarian, Fairbanks et el, 2000).

For example, a study was done by a group of clinical psychologists looking at the symptom profile associated with two different type of extreme trauma. One type was exposure to severe natural made trauma such as earthquake. The other type of exposure was collective human perpetrated violence. They compared and contrasted the different types of trauma to see the level of trauma related symptom differentiation. The study was done in Armenian Republic.

The Clinical psychologist found the people who had the highest rate of Trauma related symptoms (PTSD, Somatization, Dissociation, Affect Dysregulation, Anxiety and Depression), were the ones who experienced both significant direct threats to their lives, witnessing horrifying exposure to mutilating injuries, grotesque death, and pervasive external trauma reminders (Goenjian, Steinberg, Najarian, Fairbanks et el, 2000).

Interestingly, these types of secondary traumatic stressor results, came after experiencing a natural disaster. It is important for clinicians to remember, that these secondary stressors can also develop when human made perpetrated disasters occur, such as with the Israeli Occupation towards the Palestinians. Specifically in the refugee camps of Gaza, Jenin, Nablus, the city of Qalqilya and its surrounding villages.

Although, Palestinians did not per se, experience a natural disaster such as an earthquake, they did experience witnessing having their houses demolition by the dozens, ongoing confiscation of agricultural land, water wells confiscation, building of electric fences to racially separate the Palestinians from the Jewish Settlers, the building of an Apartheid wall almost three times the size of the Berlin Wall, in which it surrounds and encloses entire Arab cities and villages, and the ongoing Israeli military checkpoints.

Both the natural disaster of an earthquake and the human made disaster from the Israeli Occupation, create fairly identical related secondary stressors and adversities after the fact of the experiences.

These include:

	· Impoverishment
	. Homelessness
	. Overcrowded living conditions
	. Lack of food, heat, water, electricity, agricultural products
	. Joblessness

These stressors do not include the emotional, physical and financial hardships which interfere with other long term secondary stressors, such as:

	· Marital discord.
	. Disturbance in occupational functioning (i.e., urban and rural industrialization (employment, education, hospitals).
	. Social functioning.

(Goenjian, Steinberg, Najarian, Fairbanks et el, 2000).

It is important to note that the secondary stressors in this situation for the Palestinians also includes newly built military checkpoints. These checkpoints inflict high level of frustration, daily harassment by soldiers, inability to have travel mobility.

Although exposure to these two types of trauma created in both cases, did have fairly identical related symptoms (affect dysregulation, somatization, depressive and anxiety symptom), the type of exposure which the Palestinians experienced (human made perpetrated disaster) proved to show similar symptoms with people who experience severe violent trauma (i.e., being rape, being tortured or being shot by a known perpetrator). For example, clinical studies show that the individuals exposed to violent trauma tend to have higher association with:

	· Recurrent negative intrusive memories.
	. Feelings of revenge fantasies.
	. Loss of control.
	. Internalized shame.
	. Distrust/suspiciousness' of others.
	. Un-modulated aggression.
	. Somatization.
	. Suicidal.
	. High risk behavior.

(Goenjian, Steinberg, Najarian, Fairbanks et el, 2000).

Interestingly, the Palestinians who have not even been interpersonally traumatized by human made perpetrated violence, but only witnessed horrific trauma, still have a strong association link with symptom criteria list discussed above.

When specifically examining Palestinians who have experienced chronic human perpetrated violence, (i.e., victim of torture, being shot, physically wounded or beaten ), Miller, El-Masri, Allodi and Qouta (1999), found that the strongest longitudinal symptoms seen in Palestinians exposed at an early onset (below age 12 years old) were demonstrated through symptoms such as:

	· Aggression.
	. Affect dysregulation.
	. Hopelessness, helplessness.
	. Poor cognitive concentration.
	. Somatization.
	. High risk behaviors.
	. Somatization.
	. Suicidal.
	. High risk behavior.
	. Loss of control.
	. Poor impulse control.
	. Bedwetting.
	. Depersonalization.
	. Oppositional behavior.
	. Fantasizing martyrdom.
	. Nightmares haunted by bloodshed and death of people who died a martyr.

Note, there is also a significant overlap of symptoms between the Palestinians who experienced interpersonal perpetrated violence and ones who witnessed severe human made perpetrated disasters.

Furthermore, when examining emotional behavior of non Palestinians who experienced chronic human perpetrated violence at an early onset, (below age 12 years old) Van Der Kolk, Bessel, Pelcovitz, et el, (1996) found the behavior outcome to be linked with:

	· Substance abuse
	. Sexually acting out
	. Suicidal behavior
	. High risk taking behavior
	. Oppositional Behaving

In comparison, clinical statistics from Palestinian Counseling Center in Palestine, have shown that many of the symptoms manifested traumatized children and adolescents appear in emotional behavior disorders such as;

	· Fantasies about martyrdom
	. Somatization (i.e. stomach pains, chronic headaches and bedwetting)
	. Nightmares haunted by bloodshed and death of people who died a martyr
	. Chronic stress and anxiety which is seen both in the home and school
	. Extreme agitation (i.e. increase in verbal and physical fights)
	. Verbal and physical use of aggression against power authorities (schools)
	. Maladaptive acting out behavior (i.e. increase rise of illegal substance use)
	. Impulsive behaviors (i.e. hitting siblings, burning siblings with water, grabbing uncontrollably, temper tantrums)
	. Ritualistic repetitive behavior (i.e. seen in play therapy drawings of the trauma, or overly cleansing homes)

The behavioral differences seen between the two trauma exposed groups (i.e. the substance abuse, suicidal behavior and sexually acting out), can be explained by differing cultural factors. For example, the dominant Islamic religion in Palestine, strictly forbids the selling of illegal substances, acts of suicide and non marital sex. This makes it difficult to either attain the resources selling illegal substances, and /or doing culturally taboo acts).

When exploring the differences between disorders’ itself the trauma exposed non Palestinian individuals tend to have a higher prevalence of full blown PTSD. This does not mean Palestinians can not develop PTSD. In fact, this can only be determined once the occupation is over and there appears to be relatively a calm and stable country. Collective resilience within the Palestinian community appears to decrease PTSD, but other disorders tend to rise and develop taking its place. Such as:

	· Somatization Disorder
	. Conduct Disorder
	. ADHD
	. Panic Attack Disorder
	. Generalized Anxiety Disorder
	. Obsessive Compulsive Disorder
	. Mutism Disorder
	. Personality Disorders

Note in a study done by Miller, El- Masri, Allodi & Qouta (1999), they found that children and adolescents interpersonally exposed to severe trauma tend to develop one or more emotional and behavioral disorder. 70 % interpersonally exposed to severe trauma developed Conduct Disorder comorbid with the disorders above. Due to cultural reasons, more males have been exposed to interpersonal trauma. However, when females are exposed at an early age onset (6-11 yrs ) to interpersonal trauma, there is no significant differences between genders (Miller, El- Masri, Allodi & Qouta 1999). However, clinical research has shown that if not exposed to interpersonal trauma, but only witnessed the trauma, both genders tend to have a high prevalence of emotional behavioral disorders such as, anxiety or depressive disorders.

In conclusion, when trying to understand, diagnose and treat the Palestinian occupied society, it is important for mental health professionals to be cognizant of the multiple contextual factors that play a significant role in the Palestinian psyche. There has not been many conclusive comparative studies which examined the differing levels of trauma that the Palestinian have been exposed to. Neither has there been much clinical research examining the differing symptomatic effects when exposed to trauma individually and/ or collectively.

This is why it's vital to create a symptom profile trauma list for people, such as the Palestinians, so we may gain a deeper understanding and insight into their psychological traumatic experiences. Without professional clinical research with a culturally sensitive eye, it will be very difficult in differentiating the complex multiple levels of trauma which are inflicted onto the Palestinians’ daily. To heal the Palestinian soul, we, the mental health community, must first understand how their coping attitudes and behaviors are being symptomatically manifested. The emotional healing process can only begin once we truly understand the spectrum of adaptation to trauma that the Palestinians develop as a result of living under 55 years of Illegal Occupation.