"More than 50% of our patients are younger than 12 years." MSF psycological-medical-social program in Hebron

In the city of Hebron (Palestinian Territories) the ongoing violence between Israeli soldiers, settlers and local people keeps affecting the mental health of the population, and especially the children. Intrusive thoughts, anxiety, alertness, nightmares, bed wetting and poor concentration are some of the symptoms which the Palestinians have to face due to the Israeli-Palestinian conflict. Through a psychological-medical-social program, MSF continues to assist people who have been exposed or are witness to violence related to the conflict. Anja Brandal, a psychologist from Norway, has just returned from the region. In this interview, she explains how these people are affected and how does MSF try to help them cope with the situation.

Can you describe your work?

The job of the psychologists is to give short-term psychotherapy to people who have experienced or been witness to violence due to the Israeli-Palestinian conflict. I have worked with children, teenagers and adults individually, in groups or with the families. More than 50% of our patients are younger than 12 years.

There are two expatriate psychologists working in Hebron town and in the district. Each psychologist works with a Palestinian translator. We usually do home visits as, often, the patients have a long way to travel and may have to cross checkpoints. But sometimes, people prefer to come to the MSF office because they don´t want others to see that they are talking to a psychologist, even though we explain to them that it´s the situation in which they live which is not normal and not them.

When needed, we cooperate with our Palestinian medical doctor and social worker in our cases. In order to improve people's mental health, often it's necessary also to improve their medical and social condition.

Are you welcomed when you go to the houses?

Before the psychologists come to the families, two outreach field officers in the team have already done a first assessment, to see if this is a possible case for the psychologists. Afterwards the psychologists do their psychological assessment and decide if the case should be opened or not. Usually the families welcome us and are very open. Often the whole family gathers to see us in the first session before we have started the psychological intervention with one or more of the family members. Many people want us to know more about their situation so that we tell the world about what is going on in the Palestinian Territories. To do advocacy is also an important part of our work.

Which are the main concerns of this population?

In the Palestinian Territories everybody is affected by the conflict between Israel and Palestine. Some are more affected by the violence than others, and those are the ones that we try to support. In some areas they are more affected by constant harassment by Israeli soldiers and settlers, for example in the area of H2 in Hebron. This area is controlled by the Israeli Defence Forces, and the settlers live very close to the Palestinians. It's hard to live in this situation because of the aggression between the settlers, the soldiers and the local people. Most Palestinians are constantly fearing that something will happen to them or their families.

What kind of symptoms do you find?

It's normal to have reactions to an abnormal situation. Experiencing a violent event or living in an area of constant harassment affects people. At the same time many people have become used to coping with this situation, and they are managing without the support of MSF. After a trauma a lot of people have symptoms like flashbacks/intrusive thoughts, avoidance, alertness, sleeping problems, nightmares, problems with concentration, anxiety, aggressiveness. Some children develop separation anxiety and bedwetting. Through the short-term psychotherapy we provide we work on their coping mechanisms and try to reduce the symptoms.

How do they cope?

Our main job is to strengthen the coping mechanisms they already have, or to help them get new ones. Examples of coping mechanisms that make some people feel better can be talking to and getting support from their families or others, pray, do different kinds of activities like playing for children, think about something else and relaxation.

Can you explain an example of a patient you have followed?

I worked with a 14 year-old girl who had been shot by Israeli soldiers. She was very traumatized after the incident and fulfilled the criteria of Post-Traumatic Stress Disorder (PTSD). She had intrusive thoughts about the incident, was anxious, scared of being in the house without the mother, and trying to avoid thinking about what had happened to her even though she got very strong reactions when she heard high sounds or saw soldiers.

In the psychotherapy we talked about her worries, her story, how to be more independent and how she would be able to live without being alert all the time. She found ways to relax and we talked about what she could do if something similar would happen.

In this period when I worked with her there were several incursions in her house by Israeli soldiers and a lot of soldiers patrolling around the house. This is the challenge of working in a context of ongoing violence: that you have to be aware that a new incident may occur. In the case of this girl the new incidents showed that she was able to handle the situation better than before, she was still scared when it happened, but she had found ways to calm herself down and to handle the situation.

Can you explain with an example a group therapy you did with children?

I had a group of children in the district who had to pass a Israeli settlement every day on their way to school. The settlers were often very aggressive towards them. For example, they were beating them, throwing stones and eggs at them and covered their heads with masks to scare them. The Israeli soldiers escorted the children half way home to prevent the settlers from attacking them.

It was a big group of children who had experienced the same incidents and who were similarly psychologically affected. I worked with some of the children together in groups where they could share their experiences. I made them use drawings as a main way of expressing themselves, and to make them talk about their drawings afterwards. I also talked to the parents about the importance of talking with the children about their fears. After a while it was clear that the symptoms of the children had reduced, and that that they had got used to expressing their feelings which made them feel better.

Are there local psychologists?

There are only a few psychologists in Palestinian Territories, so the psychological program of MSF in Heron is very important. There are two Palestinian psychiatrists that we sometimes cooperated with or referred to, but they are very overloaded. There are counsellors working for example in the schools, but there is lack of clinical psychologists who can provide psychotherapy.

How have you felt as a psychologist working in a place like the Palestinian Territories?

At the beginning, when I arrived, it was quite difficult for me as a psychologist. I asked myself how can we manage to help the people psychologically when we can´t change the situation. This was frustrating. Then you realize you have to help them cope, help them be able to continue to live in this difficult situation. You see that many people manage to live their life in a good way, and you see that some of them manage to cope better after your work, so then you realize that your job is very pertinent.