The complexity of diagnostic practices dawned on me when I joined the newly educated therapist Ahmad at a school in Salfit, where he was to undertake psychosocial interventions. The visit to the school is part of the so-called outreach work, which recognizes that many clients are not able to come to the center’s offices for treatment due to financial constraints or fear of stigma. Outreach work is popul ar among psychosocial organizations, among the target group of clients, and not least among the donors. It is taken as a sign that the organizations, far from being elitist, are committed to helping beneficiaries who are most in need. At the Prisoners’ Support Center, well over half of the consultations took place through outreach work. The work is often done by the newest employees in the organization and thus often by those who have the least clinical experience. In the morning, the therapists travel to the village targeted for that day’s outreach work. Either they are driven by the center’s driver in its car or they take as-servīs (a minibus). Upon arrival at the villages or refugee camps, the therapists are dropped off at their clients’ houses. The driver then waits for two or three hours while the therapists finish their work.
Therapists often dread outreach work. It involves the hassle of a long journey, few or no breaks, and the frustration of not being able to do proper therapy. When the therapeutic space is the home, the client’s family, children, and guests frequently walk in and out of the sessions. At the end of the day, the weariness of the car full of therapists is palpable, and the ensuing hours of recovery long. Many of the therapists I spoke with doubted the efficiency of the outreach work, but donors like it. Given the pressure of being able to prove that services are effective and reach as many people as possible, the outreach teams I met were often under pressure to see as many clients as possible during their trips. Thus after a long car journey on the Palestinian by-roads, Ahmad, the driver, and I reached the school, where we went straight to the director’s office, outside of which three children were waiting. Ahmad asked one of the children to join him, and the other two had to wait. The case concerned a young boy who had witnessed his father being injured by Israeli soldiers in the street. The father had survived, but apparently the child suffered from concentration problems. Closing the door behind us, Ahmad took out his papers and went through the checklist for symptoms for around twenty minutes, during which time curious children constantly banged on the door and pushed it open with roars of laughter. The boy then left the room and Ahmad told me that he had PTSD and listed the symptoms from the DSM-IV. The examination of the two other children followed the same procedure. After the three consultations, we left the school and got into the car to go back to Ramallah.
The point here is not to expose Ahmad as a therapist who is not quite at home with the difficult work of diagnosis, but, rather, to reveal how the notion of trauma is, in practice, employed under the umbrella of psychosocial interventions. Psychosocial intervention is common, and would not raise eyebrows in the West Bank and Gaza, but it is worth underscoring that in its combination of an individual and social approach to the suffering person, it is based on a conceptualization of suffering as an individualized and biomedical trauma. Ahmad’s translation of the boy’s concentration problems into the language of trauma was a way for the therapist to know the boy’s affliction and therefore help ameliorate his distress. Trauma here serves as a useful proxy of suffering, and one that is a result of the many factors that influenced the therapists: donor pressure, the lack of clinical training, burnout, and the fact that the therapists often share the experiences of their clients.
With an eye to current and potential donors, the diagnosis of posttraumatic stress disorder is therefore important to Palestinian organizations because it allows them to document their activities with so-called evidence-based therapy, among them cognitive behavioral therapy (CBT). The effectiveness of CBT and narrative exposure therapy have been tested through randomized control trials of victims of rape, American Vietnam War veterans, victims of terror attacks, and British victims of traffic accidents (Bisson and Andrew 2009; Bisson 2008; van der Kolk and Blaustein 2005; Gersons and Olff 2005; Basoglu 2003). Hence, donors assume these methods will be effective among traumatized Palestinians, too.
The fact that Palestinians have to have experienced a traumatic event in order for their distress to be acknowledged goes beyond the issue of therapy. Consider Maryam, whose life figures in more detail in Chapters 4 and 5. She is the mother of three children, and her youngest son was only three when we first met. Maryam recounted how he caused her endless distress, to the point where she actually had to have him on a leash in his room in order to take care of her other children and household chores. Her mother-in-law scolded her, saying that his behavior showed she had failed to discipline her child appropriately. Two years later, she told me with relief that her son had been diagnosed with autism and that he had made fantastic progress with a new program for autistic children that Maryam herself had helped establish. With the diagnosis of her son, everyday life for her and her children had become much easier. Socially, the countless visits to her son’s doctor were no longer cause for gossip about the whereabouts of a woman with an absent husband, but rather the actions of a concerned mother caring for her child. Nonetheless, autism and other forms of congenital illness, in pariticular mental disorders, fail to attract anywhere near the same attention or funding as do disorders and traumas that are results of the occupation. And despite the historical presence of a language of psychology to acknowledge mental distress, congenital mental disorders are considered a stigma in Palestine. This uneven recognition is evident in the difference between the glitzy premises of the Prisoners’ Support Center and the “clinic” to which Maryam took her autistic son for day care, and where she volunteered three times a week: a small, shabby room adjacent to the nursery for the other children. The contrast reveals how event-based trauma is acknowledged and addressed, as opposed to the lack of recognition afforded what is described by Povinelli as the painstaking uneventfulness of chronic suffering, such as that caused by stigmatizing mental disorders (2011: 146).
Importantly, the contrast between the two is specifically owing to the presence of a violent event that enables the recognition of suffering (for an elaboration, see Mittermaier 2014). This brings to mind Das’s identification of a critical event after which “new modes of action came into being which redefined traditional categories such as codes of purity and honor, the meaning of martyrdom, and the construction of a heroic life” (1997 6). Violent events in occupied Palestine offer precisely that nexus of new modes of action and the acknowledgment that comes with being either a hero of political resistance, a martyr’s widow, or a traumatized victim.
The Force of Eventful Suffering–Immediacy and Immediation
Priority in allocating grants is given to projects providing direct medical, psychological, social, economic, legal, humanitarian, educational or other forms of assistance, to torture victims and members of their family who, due to their close relationship with the victim, were directly affected at the time of the event.
— United Nations Voluntary Fund
for Victims of Torture (2007)
Alongside the European Union, the United Nations Voluntary Fund for Victims of Torture (UNVFVT) is a major global funder for centers that offer assistance to torture victims and their families. In its 2007 round of funding, the UNVFVT had a total budget of USD 9 million. The above excerpt about the criteria for receiving funds forms the basis for the evaluation of applications and, as two members of the UNVFVT staff said during a meeting in Palais Wilson in Geneva, they continuously stressed these criteria when they had meetings or missions to visit or evaluate projects. The UNVFVT workers repeatedly emphasize to beneficiaries that the assistance must be directly allocated to the actual, immediate victims of torture.
During fieldwork in the West Bank, I joined a meeting between the Prisoners’ Support Center and a representative from the UNVFVT. The communications manager of the center initiated the meeting