Coping with trauma and adversity among Palestinians in the Gaza Strip: A qualitative,culture-informed analysis

Abstract

In this article, we propose that coping is not only an individual property but also a structural feature. Coping shapes what is referred to in social network theory as multiplex networks, which are based on relations with multiple functions, values and meanings. Focus groups with adult Palestinians were held and content analysed. Five main coping strategies were identified: (a) creating cultural and religious meaning; (b) individualism to collectivism; (c) normalization and habituation; (d) belonging, acceptance, expectation and readiness; and (e) social support. Participants also reported culture-specific expressions for indicating psychological distress. Implications for cultural informed clinical work are then discussed.

Keywords

clinical health psychology coping culture trauma war and political violence

Introduction

In the past two decades, social and health sciences have shown a growing concern for the impact of occupation, war and collective violence on civilian lives (Kleinman et al., 1997; Pedersen, 2002). Among Palestinians, the initial focus was almost exclusively on the mental health consequences of war. More recently, a broader sense of healthcare has acquired importance, with studies of well-being, quality of life and human security (Batniji et al., 2009; Giacaman et al., 2007) coming to the fore.

Within the social sciences, the effects of war and occupation in Palestine have mainly been addressed in terms of political resistance and formation of a national social memory (Allen, 2006, 2008, 2009; Hajjar, 2005; Khalili, 2007; Sa’di and Abu-Lughod, 2007). Meanwhile, less attention has been paid to describing and analysing Palestinian lives in terms of the daily routines, through which occupation and collective violence manifest themselves in people’s lives (Segal, 2016; Taraki, 2006).

Long-term exposure to political and collective violence, civil warfare or military occupation does not necessarily have serious psychological and pathological consequences (Afana et al., 2002; Pedersen, 2002; Summerfield, 1999; Yehuda and McFarlane, 1995). Understanding population-wide responses entails not only pathogenesis (i.e. De Jong et al., 2001) but also individual and collective self-protection strategies used to cope with those adverse effects.

Mental health

So far, the prevalent approach to understanding the effects of collective violence in Palestine has been based on indexing and measuring psychopathological symptoms through universal rating scales such as self-reported event exposure, coping scales, post-traumatic stress disorder (PTSD) and the Harvard Trauma Questionnaire (Abdeen et al., 2008; Afana et al., 2003; Khamis, 2015; Qouta et al., 2003; Thabet et al., 2004). From our perspective, the globalization of rating scales – in particular, self-rating scales – raises a number of issues that need careful consideration.

First, self-reporting instruments for traumatic experiences and severity of symptoms are often based on the universal assumption that notions of what constitutes a significant trauma are based on pre-structured, mutually recognized and validated social histories of specific groups. For example, these may be represented by Vietnam Veterans, torture survivors among Latin American refugees or more recently, the array of ‘PTSD of the virtual kind identified in particular after the televised catastrophe of 11 September 2001 (Fassin and Reichman, 2007; Young, 1996, 2000).

Second, most questionnaires have not been semantically validated within communities where they are being used (Afana, 2006; Pedersen, 2006). Being able to identify symptoms clinically does not imply that these have the same meaning, nor does it imply that these resonate with similar social representations across different cultural contexts (Davidson et al., 2005; Kirmayer et al., 2007; Tremblay et al., 2009). Thus, this article is seeking to identify broader semantic structures, in which symptoms are nested, to explore how occupation and political and collective violence are lived with, given meaning, and acted upon by particular communities and herein lies its main contribution to the literature.

Coping

Until now, most of the literature on the Palestinian approach to coping has focused primarily on individual coping strategies or styles. The few studies undertaken have shown an association of exposure to traumatic events and the use of active cognitive coping (Elbedou et al., 2007; Giacaman et al., 2007; Thabet et al., 2004). However, this approach was challenged by Punamäki (1997), who found that Palestinian adolescents participating in the Intifada had an increased level of psychological adjustment problems. It was also noted that boys engaged in political activity in order to cope with their traumatic experiences; hence, political activity should be classified as a resilient response rather than a pathological response (see also Harnisch, 2017, for an extended discussion of this issue). That is, the emotional reactions to stressful events, including anger, anxiety and depression may be thought of, therefore, as part of the coping process used to deal with the event.

In this wider perspective on traumatic events and the coping responses they may, or may not, generate, very little is known about Palestinian coping styles in relation to political aims, norms or values. Some studies have investigated coping among Palestinians from a quantitative perspective (Al-Krenawi et al., 2004; Thabet and Vostanis, 2004). On the other hand, a few studies, applying a mixed methods approach, have looked at the influence of political and collective violence on the quality of life (Giacaman et al., 2007). However, there is no systematic qualitative study of what constitutes coping practices and what coping means to Palestinians living in this context of protracted collective violence. Accordingly, this study was designed to better understand coping narratives among Gaza Palestinians living in a state of protracted conflict.

Coping strategy or style is first and foremost seen as an individual property, which the literature suggests has three different dimensions (Lazarus and Folkman, 2004). The first form of coping is called problem-oriented. This captures what is primarily an analytical and behavioural-change response to a stressful or traumatic event, which may then modify the perceived cause of stress. This strategy is associated with stable adjustment to stressors. The second form of coping has been defined as emotion or attitude-related coping. This operates at the level of perceptions and emotions and seeks primarily to minimize emotional distress by a change in perspective, attitudes or values. Focusing on emotions may include avoidance, as well as aggressive behaviour, a coping style that leads to depression and poor adjustment. The third form of coping is related to individual stress reduction through assistance or emotional support from social networks, whether these are close family members or community institutions (Carver et al., 1989; Folkman and Moskowitz, 2004; Lazarus, 1993). Irrespective of the coping strategy, effective coping models will promote improved psychological function despite persistent negative consequences produced by high levels of stress (Seguin and Roberts, 2017; Thabet et al., 2004).

Coping and social networks

Empirical research on how social networks and groups cope with traumatic experiences is limited. Professionals working with people living in protracted conflicts have mostly explored how terror, trauma and fear affect social imaginaries and representations (Margold, 1999; Taussig, 1992). Only a few have examined how conflict and collective violence mould social relations and larger networks (Manz, 2004; Pedersen, 2002; Wood, 2008), and thus how communities cope with collective violence and genocide, in ways that combine social interpretations of traumatic experience with practices of resistance (Zur, 1998) and/or accommodation (Harnisch and Montgomery, 2017). It could be explained that in the context of a national struggle for independence, traumatic experiences elicit social support and a collective sense of heroism that forces people to find a balance between fear and courage, and between resilience and vulnerability. In their study in Palestine, Punamäki and Suleiman (1990) described balance as a ‘conflicted state of mind between horror and heroism’ (p. 74). They found that severe military trauma did not negatively impact children’s creativity or self-esteem, while good family relations even enhanced these resiliency features (Qouta et al., 1995).

In fact, we argue that it is difficult to understand individual coping styles without explicitly considering the ways in which social encounters, kinship relations and networks mediate coping, which is a view of coping highlighted by Abu Nahleh (2006), in her masterful ethnographic essay on six multigenerational family histories from Palestine. In this study, she pays close attention to the political and social contexts while tracing how these contexts shape effects (i.e. stress of the male provider) and social responses (i.e. marriage strategies), and how expressivity (i.e. afflictions and symptoms) is shaped, with a need to elicit support and to manage networks of a social or political nature. In her recent monograph, Segal (2016) further develops these ideas, eloquently demonstrating how trauma and other emotional responses (loss, grief, shame, isolation) among a small group of Palestinian prisoner-wives in a village on the West Bank are moulded by their sense of community and the normalcy of a gendered clan and family structure. She demonstrates clearly how the ways in which Palestinians cope with occupation and collective violence is shaped by their social networks and the meanings they ascribe to the relations within those relationships. Likewise, in a case study from Amari refugee camp, Palestine, Johnson (2007) demonstrates clearly how talk and action modes are so closely intertwined, that in many situations, it is difficult to separate the two, thus indicating a networked nature of coping.

Culture and religious coping

In addition to social networks, religion has been found to strongly influence the Palestinians’ understanding of the world, in much the same manner that it provides meaning to a reality of suffering, making it more comprehensible and hence also more bearable. The majority of Palestinians rely on religion as a component of their self-identity. Religion imparts explanatory mechanisms, including meaning, purpose and specific aetiologies. It also provides healing and coping mechanisms for distressful situations (Al-Krenawi et al., 2004). Religion provides meaning to traumatic experiences thus helping Palestinians to cope with upheaval. In addition, religion has both belief-related and motivational components by giving meaning to peoples’ lives and enhancing social support and cohesion.

In periods with high levels of stressors, religious belief systems and practices provide shared registers of interpretation and action. Prayer, meditation, positive religious interpretation of adverse events (positive religious coping) or negative interpretations of God as avenger or punisher (negative religious coping) provide believers with means of coping. Thus, Islam, as other religions do, plays a positive role in the life of its followers, providing comfort, meaning, identity, spirituality and community (Pargament, 1997).

Culture, as we define it for the purposes of this article, is shared and learned and is embodied as a symbolic system of values, beliefs and attitudes that shape individual perception and behaviour (Barth, 1990; Dwairy, 2009). One of the primary characteristics of culture is that it provides a context for how to survive as a human being and as a member of a social group. It, therefore, has a regulatory function, which assists in dealing with disorder and traumatic events as well as their causes. Cultural systems thus provide useful repertoires of beliefs and constructs that enable individuals and groups to cope with trauma when it arises (Knipscheer and Van Tilburg, 1999). Hence, coping is a dynamic process represented by a series of transactions between a person who has a specific set of resources, values, beliefs and commitments, in a particular social environment, with its own resources, demands and constraints. As defined by Lazarus and Folkman (1984), coping is the process of managing demands (external and internal) that are considered as taxing or exceeding the resources of the person. Therefore, the relationship between coping and a stressful or traumatic life event is a dynamic process, wherein the environment and the person influence one another. The emotional reactions to stressful events, including anger, anxiety and depression, can be thought of as part of the coping process used to deal with the event.

In this article, we propose that coping is not only an individual property but also a structural feature. If we draw on social network theory, coping can be seen not only as an attribute of the node (individual properties in the behavioural, emotional or cognitive terms outlined above) but also as a structural property of the network itself. Hence, abilities to cope with traumatic experiences are shaped by individuals themselves (nodes) as well as by the ways in which coping mediates the effects of violent and traumatic events. Thus, coping shapes a multiplex network of structural properties, that is, shaping hierarchies, groups or structural holes. We believe that measuring coping in terms of outcomes (positive or negative) alone is not enough to provide an understanding of emotion and adaptation. Achieving personal meaning and social representation of a stressful or traumatic situation is an important step towards viewing coping as a part of the domain of emotion and motivation and not just a decision that a person makes. To truly understand coping, we must focus on the meaning of the situation and the interaction of the people involved within their own environment as well as their motivations.

Methods

This qualitative study is based on a series of focus group discussions held in 2012 with refugees who had escaped from Israel in 1948 (after the Al Nakbah or the catastrophe) resulting in the establishment of the Jewish State, and who had been living in Gaza Strip camps since that time. Participation was voluntary, and a food basket was given as an incentive and in support of each participant family. The inclusion criteria for participants included their living in a refugee camp, having suffered a serious personal loss in the past 10 years (i.e. loss of close kin or a house demolition by the military) and having at least achieved a preparatory school certificate.

Participants

Recruitment was conducted in collaboration with the Palestinian organization Jesoor for Trauma Recovery, which is a local non-governmental organization (NGO) that works on mental health issues, and that offered space to field workers as well as a research assistant, who contacted participants for group discussion. Each focus group lasted approximately an hour and fifty minutes (110 minutes). The research assistant was a reputable counsellor with extensive experience in the organization, who was acknowledged as a reliable and authoritative figure by the beneficiaries of Jesoor’s work.

An initial screening of participant candidates, eligible for the research, was undertaken by Jesoor coordinators, who created a list that the assistant researchers used for further selection. Selection criteria included the plausible willingness of the person contacted to participate in the exploratory study, their not having been diagnosed with any severe psychopathologies (psychosis, personality disorders etc.) and suitable physical health that would permit them to travel from home to Jesoor headquarters. The result was a sample of 34 persons (18 men and 16 women; M = 27.3; standard deviation (SD) = 0.56; age range 18–40) who then participated in four focus group discussions. The men and the women participated together in the discussions. The fact that the local NGO was familiar and highly trusted and that the assistant researcher, who was well-known and clearly acknowledged as a member of the host institution, allowed any possible cultural and societal barriers, such as gender issues, provenance from different families or political factions, to be mitigated. Only verbal consent was obtained due to the personal risks generated by the current socio-political situation and for reasons of the participants’ safety and security. The participants’ concerns about their privacy, anonymity and confidentiality were discussed and complied with before conducting the interviews. All participant identities were kept strictly confidential. Study data were stored on a password-protected portable computer. The interviews and discussions were audio-recorded with the participants giving explicit oral consent statements. It was mutually agreed that the research results would be published while preserving the anonymity and confidentiality of all personal information.

All participants in the study were from lower-middle-income families of the Muslim faith. Their occupations included teachers, homemakers, civil servants and manual labourers. Everyone participated in at least one of the focus group discussions.

Instruments and procedures

Semi-structured open-ended questions were posed to ask the participants to describe their daily life and current events in the Gaza Strip. These elicited local expressions of distress, the meaning of traumatic experiences, the nature of coping strategies and the healing methods practised by the Palestinians. Participants were also asked to list the traumatic events they had experienced and to grade their relative severity. This was inspired by a previous study that identified the social meaning and expression of traumatic experiences in the Gaza Strip (Afana et al., 2010).

Participants were asked the question about the painful events they had experienced: ‘What are the main or most important painful life events (Ahdath Muli’ma) you have experienced?’ ‘How did these events affect you individually? And collectively?’ Participants were also asked to reflect on their responses with follow-up questions, ‘How did you deal with these events? And what sort of support was available?’

Data analysis

The focus group discussions were audio-recorded with the consent of the participants, who were guaranteed anonymity. The discussions were later transcribed by a research assistant. Names of persons, places and other identifying details were encoded to protect anonymity and confidentiality. The interview transcriptions were analysed with regard to content, themes and structure using ATLAS.ti 5.0. We were interested in a phenomenological analysis that focused on the system of meanings that guides the perceptions and social representations of each participant individually and as part of a group. The contents of the transcripts were examined along two axes. A vertical analysis, which implied an analysis of the narrative within each participant’s response and a collective analysis, sought meanings emerging across participants. The individual vertical analysis sought to detect a local consistency of terms used in the responses. Then, a horizontal analysis compared and contrasted themes across individual responses. Similarities and differences emerging from different stories were used to develop a set of categories, which indicated the existence of structures that inform social representations and meanings within the strategies used to cope with traumatic experiences (Afana et al., 2010).

Ethical issues

The research, which was approved by a local institutional ethics committee (IEC), the Helsinki Ethics Committee in Gaza, was conducted for scientific purposes only. Its aim was to benefit these peoples’ mental and physical health and improve the delivery of services to the entire community. Although the participants were not asked about personal experiences, the provision of counselling and therapy was secured for those participants who expressed a need for psychological assistance. Participant identities continue to be kept strictly confidential. All electronic data and the raw audio recordings are stored on a secure, password-protected and encrypted server.

Results

The study identified five main coping strategies that Palestinians in the Gaza Strip use to deal with painful experiences and atrocities. These were, (a) giving cultural and religious meaning to painful experiences; (b) moving from individualism to collectivism; (c) normalization and habituation; (d) belonging, acceptance, expectation and readiness; and (e) social support and expression of distress (‘maintaining an intact sense of purpose’ and ‘coping with war’).

Creating cultural and religious meaning

The belief in the power and control of Allah over a believer’s life and death becomes a belief in fatalism and destiny, known as ‘ qada ’ and ‘ qadar ’. This belief gives Palestinians a rationale for survival and an ability to cope with a violent and destructive environment. As many informants expressed it,

[…] As Muslims we have beliefs, we believe in qada and qadar , the person who believes even just a little leaves the whole thing for Allah […]. (Man, age 30)

[…] I think people have become qadareen (believers in fate and destiny) and If Allah wants me to die, I will, and no human being can stop that and if Allah wants me to stay alive, not to die, no human being can stop that […]. (Man, age 40)

[…] Without religious beliefs, modern intervention methods will not be fruitful people are aware that everything is Allah’s will, every person might be affected if Allah wants … mmm … this makes people cope better, adjust and avoid mental health problems, you know, Allah gives them the strength and ability to deal with all these things […]. (Woman, age 35)

Ascribing suffering and hardship to Allah’s intention to test ( balua ) people’s patience and religious beliefs gives meaning to participants’ traumatic experiences and to the loss of their loved ones. Belief in the rewards of an afterlife also makes it easier to cope and survive by giving order to the disruption and chaos of their lives:

[…] In religious terms balua starts with the self, either by disease or death. This is the first thing. Second, balua is either death of the son or sickness of the son. Disease includes the person being injured or something like that. Third, in capital issues (money), a house like this obviously costs a lot of money, suddenly the house is demolished by Israeli missile or tank … the more iman (religious belief) you have the more rewards you will receive […]. (Man, age 39)

[…] You will have ajer [rewards] from Allah if you lose a son or beloved person and say: ‘la hawla wa la kuwa ilah be Allah’ [in Allah we believe and in no power except the power of Allah] … you will be rewarded […]. (Man, age 25)

Believing that their life has a purpose, and living in Palestine (the Holy Land) is their major reward and believing that they are expected to defend their land, provides meaning and gives them strength to resist their despair:

[…] We are in the Holy Land, which is mentioned in the Holy Quran and that those who live in the Holy Land are tested for the day of life after … all of us are leaving this earth. People who have kudra imaniah [strong religious beliefs], if they lose everything, will not be affected. They believe that life is transitional, everything is going to disappear, and nothing will be left except the afterlife […]. (Woman, age 28)

[…] People with iman [strong faith] will sacrifice everything including his/her soul for the sake of Allah. Allah has brought everything for believers including their souls for paradise […]. (Man, age 20)

Clearly, Palestinians systematically use positive religious coping strategies because their religion imparts explanatory mechanisms, including meaning, purpose and specific aetiologies.

Individualism to collectivism

The basic assumption of individualism is that individuals are independent of one another, while collectivism subsumes that communities bind and reciprocally obligate their members (Oyserman et al., 2002).

Participants indicated that their sense of shared experience, where the whole community is targeted and punished, gives meaning to collective coping, which enables their own survival. The notions of self-hood and communal identity, in which one has responsibility for others, exist for others facing the same destiny, and even the perception of not being alone and not being targeted as a single individual provides impetus for survival and plans for their future:

[…] We all face the same … we are all targeted … what is happening is not happening to me alone […]. (Woman, age 19)

[…] Because the problem is collective, all people suffer, all people face the same situations and there is nothing the individual can do. All people are equally at risk. These events are directed at all of us, not towards any specific person […]. (Man, age 19)

[…] It is collective, the whole community suffers even … even the person who is attacked has no way out and has to accommodate with the surroundings. There is no way out for the individual; usually the way out is through religious beliefs and actions […]. (Woman, age 20)

This collective identity facilitates Palestinian coping with stress and traumatic experiences. It creates community solidarity, kinship support and the ability of individuals to understand the political situation and it provides protection against fear, despair and helplessness:

[…] A person exposed to trauma who is surrounded by people will of course get support and help from his wife, sons, neighbours, and relatives […]. (Woman, age 21)

Normalization and habituation

Normalization and habituation processes imply the attempt of victims of chronic and ongoing violence to normalize their situation with everyday life and foster resiliency within abnormal living conditions (see Nguyen-Gillham et al., 2008):

[…] We are used to these events; it becomes part of our daily life […].

Palestinians have been long exposed to protracted traumatic events. In the face of these continuous attacks, individuals have become habituated and are expecting the attacks at any time:

[…] I want to tell you, because we see a lot of things in this life, someone might say why should I care, for example, the person considers them (events) part of daily life […]. (Man, age 40)

Becoming ‘numb’ to traumatic events or becoming habituated to these attacks, people make use of these events and develop coping strategies to lessen the impact of these events:

[…] Now, it seems that people are gradually becoming habituated to these views. Because of lack of optimism, continuous attacks and frequently seeing and passing through these events, people become habituated, adjusted to such situations […]. (Man, age 32)

[…] I think and believe that everyone considers these events as part of their daily routine, which is of course not the normal life that Palestinians are hoping for and expect […]. (Woman, age 30)

Habituation and seeing these events as part of life may also indicate a Palestinian’s ability to suppress traumatic memories and the painful feelings associated with them, which could be considered a major coping strategy used by the participants that enables them to continue.

At the beginning of the first Intifada in 1987, when someone was shot or wounded, the community would react by expressing their sorrow in large demonstrations. Gradually people became accustomed to these events. They tried listening to the news less to try to stop thinking about the situation or to pretend not to remember the sadness:

[…] The ability of the community to live in such an abnormal situation is considered one of our main strengths as Palestinians … If you bring ‘Western’ people to live here they would not last even a few months mmm no I think they would not even be able to live here for a few weeks […]. (Man, age 40)

The participants indicated that people describe their efforts to keep busy with many activities to avoid thinking of different pessimistic emotions such as feelings of powerlessness, helplessness and hopelessness. Although this strategy has been described as effective for dealing with immediate danger and trauma (Carver et al., 1989), there was some indication that this strategy was not very effective over the long term (Goodman, 2004).

Belonging, acceptance, expectation and readiness

[…] We are living in the Holy Land under occupation and we expect this suffering […]. (Woman, age 25)

Participants indicated that living in Palestine (the Holy Land) under occupation and collective violence is part of the burden of those who have to live there until the Judgement Day (end of human history) because it is their fate. As a part of a larger Muslim and Arab history, these sufferings are known, expected and meaningful (Al-Krenawi, 2005). It is very important to remember the significance of staying in that land, as several participants concurred:

[…] We live under occupation. What do you expect from occupying forces? […] (Man, age 32)

[…] This is not a life … people are obliged to deal with this life, not one of us would like to live such a life but we are obliged to […]. (Man, age 35)

[…] What makes people cope and adjust to the situation is the external enemy … It is expected that our enemy impose all these events and we do expect to pay a high price for our struggle and liberation […]

[…] This culture spreads only in the Holy Land, here in this place, that is what our prophet Mohammed describes as belad el sham (i.e. people who live in Palestine and will not leave the holy land), and we are rebat (bound) till the day after. These are the characteristics of people living in this land. It is embedded in our personalities […]. (Woman, age 35)

[…] We are rebat for yaum el deen (we are bound to this land until the day of judgment) […]

[…] We expect the Israeli army will demolish farms and houses, uproot trees, kill … We expect everything Israelis might do […]. (Man, age 35)

[…] Acceptance of these events with patience and living in the Holy Land, everything is from Allah, let us die as martyrs and so all are part of coping with these events […]. (Woman, age 22)

Family support

In Palestine, the extended family provides social support, enhances community networking and helps to build trust among family members (Atallah, 2017). The cultural capital invested by the family on their members is considered one of the potential resources that keeps family cohesion and strengthens its extra-family network:

[…] Social ties and social support have started to decline compared to a few years ago because of social change that happened in the Palestinian community.

I remember when there was a funeral in a neighbourhood, everyone would get together and there were no other celebrations for three days … You know these days are to support the family […]. (Woman, age 38)

Traditionally, the family is the most important social unit. It is more important than the individual, in terms of identity, status and interpersonal relationships. In recent years, the long-lasting military conflict and the collective trauma have both increased social cohesion and caused disruption in Palestinian society.

The protracted and long-lasting political conflict and collective punishment have increased social cohesion and support. However, according to Punamäki et al. (2001) and Qouta et al. (1995), much of the social support system has been shackled by systematic targeting of the extended family structure by occupying forces as well as by internal violence caused by confrontations between factions and political parties. Based on their findings, certain factors have contributed to the deterioration of social support systems such as parental roles and family unity, whose influence over adolescents has declined in favour of the political parties. As a result, the parenting styles practised by caregivers were perceived as non-supportive mainly among youths and adolescents. In addition, the long-lasting occupation and the fact that the peace process has achieved no tangible results have contributed to adolescents taking a more active role in their struggle for liberation. In a sort of role-reversal, they are now substituting the previous generations, which are perceived as submissive and depressed and therefore incapable of effectively confronting the occupiers:

[…] How many events a person lives through and their ability to face and adapt to those events affects their personal behaviour, their psychological immunity, in addition to their life experiences […]. (Woman, age 22)

Expression of distress

In addition to the five categories of coping described above, participants also provided 16 emotional terms that describe their suffering from traumatic experiences. These terms can add information and give some sense to the strategies that Palestinians living in Gaza must continuously mobilize in order to cope with their abnormal and ongoing traumatic reality. The idioms include fear and sadness responses ( khoufa, hazeen ), irritability and nervousness ( arak nafsi and asabiah ), some clear psychological expressions such as psychological pressure ( daget nafsi ), psychological crisis ( azamat nafsiah ) and psychological persecution ( idehad nafsi ). Some of these idioms are associated with traditional expressions such as madness and foolishness ( majnoon and hawas ).

Mental illness is often associated with certain expressions such as my head is empty ( rasi fadi ), nervous breakdown ( inhiar assabi ), feeling a gust or an outburst ( tafran ) and freezing of feelings ( tabalud fe el masha’r ). Table 1 contains the list of the most common idioms that describe psychological suffering. These idioms are often used whenever people experience negative psychological and mental health conditions.

Table 1.

List of the common idioms of psychological distress.

	Local idiom	English translation
1	arak nafsi	Irritability or interruptions of sleep
2	asabiah	Nervousness or nervous
3	azamat nafsiah	Psychological crisis
4	daget nafsi	Psychological pressure
5	Inhiar Assabi	Nervous breakdown
6	Hawas	To be baffled, startled, foolish
7	kalak	Worried
8	Mahbul	Stupid, idiotic, fool
9	khoufa	Fear syndrome
10	Majnoon	Mad
11	tabalud fe el masha’r	Freezing of feelings, numbness
12	Tafran	I feel gust, outburst, surge
13	Tayah	Astray (low confidence and self-esteem)
14	Rasi Fadi	My head is empty
15	Mahana	Hardship, suffering, tribulation
16	Idehad nafsi	Psychological persecution

The majority of the participants who were asked about PTSD indicated these terms and phrases as the most common ways used in the place of PTSD: Sadma, faji’ah, musiba, balwa and nakba . They described their flashbacks as the feeling that a past event was happening all over again. Most participants stated that they could easily remember those event(s) and reported that they were unable to forget them. Somatic complaints such as headaches, back pains, gastric conditions, palpitations, burning sensations around the extremities, fatigue, pain in the whole body (broken body) and tightness in the chest were the main physical symptoms associated with these traumatic experiences.

When participants were asked to list their traumatic experiences according to the severity of the event, their responses indicated that the loss of loved ones, their homeland and their homes in house demolitions were the most severe traumatic experiences. When the severity of traumatic experiences was compared between genders, loss of loved ones, loss of homeland and loss of the home were the most severe among the women. These were followed by environmental conditions brought about by the occupation such as daily shelling, witnessing killings; night raids and incursions; closures, the destruction of infrastructure; and frequent water and electricity cuts (Table 2). The men also reported the loss of loved ones, loss of homeland and of their homes as the most severe traumatic experiences. Here, the men diverged from the women with their stating that imprisonment and torture, living under occupation, closures, witnessing death and destruction and living in refugee camps were the next most serious traumas they had to live through.

Table 2.

Severity of traumatic experiences according to gender.

	Women	Men
1.	Loss of a brother, sister or loved ones	Evacuation from homeland
2.	Your own house being demolished	Loss of a brother, sister or loved ones
3.	Evacuation from homeland	Your own house being demolished
4.	Separation from the loved ones	Night raids and incursions
5.	Living under daily shelling and sniper killings	Being imprisoned, tortured and abused
6.	Witnessing killings and seeing human remains	Demolition of infrastructure (bridges, electricity etc.)
7.	Night raids and incursions	House demolition
8.	Witnessing torture	Separation from the loved ones
9.	Electricity and water frequently interrupted	Restrictions on travel and internal movement by checkpoints
10.	Forced to dance in the street	Witnessing killings and seeing human remains
11.	A place where borders are closed, a prison-like feeling	Witnessing or experiencing uprooting of trees and destruction of farm fields
12.	Being imprisoned, tortured and abused	Living in a refugee camp
13.	Demolition of infrastructure (bridges, electricity etc.)	A place where borders are closed, a prison-like feeling
14.	Restrictions on travel and internal movement by checkpoints	Being imprisoned, tortured and abused
15.	Living under occupation	Witnessing torture
16.	Witnessing someone else’s house being demolished	Living under occupation
17.	Sudden and unexpected air strikes and sonic bombs	Electricity and water frequently interrupted
18.	Witnessing or experiencing uprooting of trees and destruction of farming fields	Living under daily shelling and sniper killings
19.	Living in a refugee camp	Unpaid work
20.	Unpaid work	Forced to dance in the street
21.	House demolition	Witnessing someone else’s house being demolished

Discussion

The study suggests that coping among Palestinians in Gaza is a dynamic process rooted in their strong beliefs in their just cause to liberate their homeland and to live in peace and dignity. These beliefs have shaped their expectations towards their occupier. Their capacity to endure their traumatic experiences and atrocities can be understood in a wider political and environmental context. It is rooted in their making their life as ‘normal’ as possible. As indicated by the participants in this study, these events have become part of their daily life. Given that Palestinians have been exposed to daily traumatic experiences for a protracted period, and that many have not developed psychopathological conditions as a result of this exposure, important questions arise concerning the Palestinians’ perception of traumatic events, as if they had ‘normalized’ these events as parts of their daily life. Those who witness demolitions, destruction of infrastructure or injuries perceive these events as ‘traumatic’ or ‘distressful’. Perhaps, the Palestinians even expect to experience these events, as they live under occupation and in an environment of constant political violence.

Some studies from South Africa, Northern Ireland and Palestine have shown that active participation and/or ideological commitment to political struggle can increase resilience and enhance coping strategies (Carins et al., 1989; Punamäki, 1996; Straker, 2007). Punamäki et al., in their series of studies in the Gaza Strip, found that stronger ideological commitment among Israeli children was related to fewer psychological problems and that higher exposure to traumatic events was likely to produce more commitment to their cause of liberation and protect children from the negative impacts of collective violence (Punamäki et al., 2004; Qouta et al., 2008).

In the Palestinian context, studies showed the complex interaction between exposure to traumatic events and active participation and beliefs (Punamäki and Suleiman, 1990; Qouta et al., 1995). In a follow-up study in South Africa, Straker (1996) found that a high level of reported exposure to political violence lead to a subjective sense that violence was problematic. A similar study conducted by Baker (1999) found that children with mothers who were able to provide a routine and support through stories, activities and ways of protecting the family were less likely to develop psychological symptoms. What this study clearly showed is that families, peer groups, community support and active involvement in the resistance movement provide organization and structure within daily life.

To fight for a cause and to be active in political struggle means sacrifice and reward; being passive leads to humiliation and shame (Nguyen-Gillham et al., 2008). Sacrifices on the road to independence and the rewards they believe they will receive in the afterlife enable Palestinians to deal with atrocities. This commitment to the road to liberation signifies an individual and collective coping as an act of resistance, reinforcing shared beliefs and communal belonging. What we have understood from our data is that when traumatic events involve personal death, uncontrollable events and/or other existential issues concerning the meaning and purpose of life, Palestinians use existential spiritual or supernatural beliefs, which might be weakened or strengthened by time, to address these issues. Using religious beliefs and an organized religion as a resource helps these people increase their sense of control, intimacy and their ability to find meaning. All of this may lead to a new philosophy of life that alters the basic assumptions that most people hold about life (Al-Krenawi et al., 2004).

Traumatic experiences among people living in situations of protracted conflict and war differ from what are viewed as standard post-war contexts in at least two fundamental aspects. First, these people were and continue to be exposed to continuous, repetitive and multiple traumatic events that in many ways shape their daily life. Second, the cultural meaning attached to and the social representations of these traumatic experiences may help people to cope with those same traumatic events (Goodman, 2004; Punamäki et al., 1997).

In the past few decades, research has increasingly focused on ‘coping resources’ and ‘coping processes’ that individuals use to deal with traumatic and stressful life events (Canetti et al., 2010; Hobfoll et al., 2011). In their unique study, Canetti et al. (2010) found that losses of interpersonal and intrapersonal resources related to socio-political stressors and collective violence were stronger predictors of both PTSD and mental disorders. In view of our findings, we question the instruments used to measure coping used in previous studies because they did not consider cultural and political contexts. Coping is not just an individualistic approach, however. Individuals in this study were seen to be using both types of coping: ‘cognitive’ and/or ‘emotional’. Clearly, coping does not exist in a vacuum. The strategies applied by the Palestinians were not static and they were influenced by their environmental surroundings. In the conflict in Northern Ireland, Devine-Wright (2001) found that ‘commemorations’, which is a form of collective action that attempts to legitimize and defend the group’s status in the face of threats while also offering a means to strengthen group cohesion, enforce a sense of belonging and social identification at an individual level. As described in the literature, coping is a dynamic process wherein the environment and the person influence one another.

In a study of Palestinians, Punamäki et al. (2004) showed that ‘mature defences’ such as anticipation, sublimation, suppression and rationalization were used in response to traumatic experiences; these defences were associated with low levels of PTSD among Palestinian men. In another study, Punamäki et al. (1997) found a positive correlation between exposure to traumatic events and the use of active cognitive coping reported among Palestinian children. In another study in the region, Thabet et al. (2004) found that a large number of Palestinian adolescents relied on emotion-focused styles, particularly the acceptance of their faith in God, which was used almost all the time by 79 per cent of the respondents.

Coping styles and cultural resiliency need to be examined further to fully understand these findings as well as the experiences of non-Western populations faced with political and collective violence in contexts of protracted conflict.

Since 1948, Palestinians have experienced oppression, multiple, repetitive and continuous traumatic experiences, social exclusion and related socioeconomic and political problems. Palestinians describe the 1948 war as Al Nakbah or the catastrophe. For them, it represents the loss of their homeland, livelihood and political power. It also represents the disintegration of society, the frustration of their national aspirations and the beginning of the rapid destruction of Palestinian culture. Al Nakbah was the moment when a majority of Palestinians became homeless, a status associated with a deep sense of insecurity and memories of loss. The home became a key symbol to the Palestinian people and returning to their homeland became a dream passed on through generations as a way to connect to the land. That alone explains why home demolition was ranked among the first two most traumatic events experienced by both men and women.

The strong identification with the aspirations for Palestinian nationhood seems to offer psychological protection to children facing high levels of collective violence. The meanings developed for those traumatic experiences play a central role in the incompatibility of those traumatic experiences (Kline et al., 2003). The concept of trauma in the Palestinian context is different from Western definitions based on Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (Text Revision) (DSM-IV-TR) PTSD diagnosis. Palestinian society views being exposed to trauma as part of their struggle for liberation. El-Helou and Johnson (1994) reported that teenagers in the Gaza Strip coped with their traumatic experiences by practicing religious rituals, such as praying and going to mosques for religious practices. Because of the unique social experience in the population of repetitive trauma and protracted collective violence, particularly in the Gaza Strip, there is an urgent need among local mental health professionals to understand the cultural registers of traumatic experiences as well as the existing coping styles that reinforce resilience and social cohesion.

Another important coping strategy in the Palestinian and Arab society, in general, is the belief in the power of fate and acceptance of what God brings (Afana, 2006; Khamis, 2008). The socio-moral meaning of an event is understood as a test from Allah (God) that must be handled with patience to gain the reward of religious growth. In this context, acceptance of the event becomes a way of demonstrating one’s strong religious commitment. As a way of justifying painful events and cope with them in an acceptable manner, Palestinians use a common traditional proverb to help them to accept the consequences of that event: ‘what is written on the forehead, must be seen by the eye’. The main purpose of this belief is to empower the individual to accept the outcome of all encounters: if failure ensues, then fate is to blame. A belief that one has no control over life events is closely linked to fatalism. In her study, Khamis (2008) showed that Palestinian adolescents who believed in fate and used more ‘negative coping strategies’, such as distraction, withdrawal, criticizing self, blaming others and wishful thinking, were more likely to show symptoms of anxiety, depression and above all PTSDs. These findings are similar to those of Punamäki et al. (1997). There is considerable evidence indicating that a positive sense of control over one’s life is essential for maintaining health and well-being (Crescenzi et al., 2002). However, the idea that accepting fate as controlling one’s life may also have similar effects as having a positive sense of control.

Limitations and implications

The fieldwork and implementation were slow because of the siege imposed on Gaza. The lack of basic life requirements such as fuel and food, along with frequent interruptions of electricity and the school system, together with a shortage of healthcare facilities, influenced the implementation process of the fieldwork in terms of the number of focus group discussions and participants involved in the research. The shortage of fuel made finding transportation more difficult and very expensive.

Furthermore, a certain level of social desirability could have also influenced the results. In fact, the expression of opinions in contexts characterized by a high level of social control such as in Muslim collectivistic societies can be strongly influenced by fear of being judged and/or stigmatized by other interviewees (Meade, 2012). This means that the people were unable to feel free, for example, to state that they were not benefitting from religion as a source of coping. This source of interference on reliable findings is not easily controlled. However, we suppose that, as posited by certain sociological theories on social control, reciprocal control of specific and pivotal key values in a society can favour the mobilization certain sources of coping strategies among individuals sharing those values. Indeed, people, through mechanisms of mutual control, can internalize core values, such as religion in the Muslim society, and use them as a source of coping. On the other hand, people who do not use this culturally informed coping strategy can be considered more at risk and exposed to stressors. Accordingly, during the focus group discussions, the facilitator was trained to moderate the conversation, avoiding questions that might increase judgmental phenomena and to control reciprocal aggression or disqualification.

This qualitative study has highlighted the complexities involved in applying Western coping instruments since the question of how Palestinians in the Gaza Strip interpret and construct their own pathways to deal with their traumatic experiences and atrocities cannot be answered. However, our study does highlight some key domains related to this issue. The Palestinians’ determination and connectedness to their national cause and to the liberation of their homeland are highly rooted in their ways of interpreting their suffering (Barber et al., 2014). By ignoring the political and social context, we contribute to an unhealthy environment for Palestinians living in protracted political conflict and we also reduce our therapeutic effectiveness (Veronese, 2013; Veronese et al., 2016). Avoiding the root causes of the problem, medicalizing the political, social, communal and existential suffering while individualizing people’s reactions to collective violence de-contextualizes such human atrocities to the point that one risks undermining the victims’ struggle and contributing to the efforts of their oppressors (Giacaman, 2017).

A social context such as Gaza, the site of an endemic and protracted conflict for several decades, offers an important possibility for gaining a more nuanced understanding of the social survival and coping strategies experienced and employed by its members. This study has given us critical knowledge on how Palestinians navigate through their daily lives and how they deal with the consequences of the collective violence that permeates their daily experience. Furthermore, a great deal of significant data on the cultural meaning of traumatic experiences for Palestinians has been provided through the semantic mapping of local idioms of distress and the role of religion in providing explanatory mechanisms such as meaning, purpose, healing and coping. The resulting body of knowledge could provide significant opportunities to improve interventions and mental health services for populations living in a society characterized by intractable conflict. Therapists who are trained in the West have ethical, moral and professionals responsibilities to incorporate their social, political and cultural perspectives in the Western model. They need to apply culturally adapted models that incorporate past, present and future-oriented scenarios for their clients and for themselves: models that focus on strengths rather than weakness, resilience rather than illness and health rather than disease.

Footnotes

Acknowledgements

The authors would like to acknowledge the pioneering work of Professor Duncan Pedersen of McGill University in Quebec, Canada. Dr Pedersen passed away suddenly during a trip to Peru while doing what he had committed his entire career to – global mental health. Dr Pedersen was an international leader in global mental health, a wonderful teacher and a mentor to many. His commitment to global mental health was unique and he reached many communities all over the world. He was a pioneer in the field and an empathic global citizen. He will be missed and we dedicate this paper to his memory and his work.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Guido Veronese

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