The ambiguities of social inclusion in mental health: learning from lived experience of serious mental illness in Ghana and the occupied Palestinian territory.

PURPOSE: Social inclusion of people living with serious mental illness is widely promoted. However, only limited consideration has been given to the meanings of social inclusion within different settings and the ways in which it is envisioned, negotiated, and practised. In this paper, we explore meanings and practises of social inclusion from the perspectives of people living with serious mental illness and their families in Ghana and Palestine and how this is shaped by differing political and socio-cultural contexts. METHODS: This paper draws on comparative ethnographic research including participant observation and interviews with people living with mental illness and family members in Ghana and the occupied Palestinian territory. Data were triangulated and analysed using thematic analysis. RESULTS: Participants described experiences of social inclusion and participation within communities, home and family life, friendships and social life, and work and livelihoods. This revealed how such experiences were variously shaped by differing political contexts and socio-cultural norms and expectations within the two settings. These in turn intersected with aspects such as gender roles, age, and socio-economic status. Aspirations for inclusion included greater awareness and understanding within society, accompanied by opportunities and support for meaningful inclusion at the political as well as community level. CONCLUSION: Findings point to the value of a contextual understanding of social inclusion, taking account of the impact of the wider socio-cultural, political, and economic environment. They also point to the need for an intersectoral approach, beyond communities and mental health services, to provide meaningful opportunities and support for social inclusion.

Fathers detained, contact restrained: Experiences of Palestinian children visiting their fathers in Israeli detention.

BACKGROUND: Very little is known about the experiences of children of political prisoners internationally, because of the challenges of researching within politically oppressive contexts. OBJECTIVE: The aim of this secondary analysis was to explore and understand Palestinian children's experiences visiting their fathers in Israeli detention. PARTICIPANTS, SETTING AND METHODS: Qualitative data from sixteen in-depth interviews with thirty-one children were analyzed. Structural and longitudinal coding cycles were employed and focused upon the timeline of the visitation process. RESULTS: Three overarching themes emerged, which included: Children's experiences 'before the visit', 'during the visit', and 'after the visit'. Subthemes related to the distressing and at times traumatic experiences the children suffered throughout the process of preparation for, going through, and the aftermath of the visit. This included reports of experiencing punitive measures at checkpoints and waiting areas and humiliation and maltreatment by the Israeli authorities during the visitation process. These findings are discussed with reference to the United Nations Convention on the Rights of the Child. It was clear that the children's best interests were denied and contact and interaction with their fathers was restrained under the Israeli visitation scheme. Despite the arduous visitation process that children often hated, they loved to see their fathers. CONCLUSIONS: Even though the children's rights were infringed upon, they still endured hardships to maintain whatever contact was possible. International advocacy for the realization of the 'rights of the child' for Palestinian children, as well as other children of political detainees is warranted.

Well-being and pressures of daily life in two West Bank villages-Exploring context and history.

Interest in the well-being of people exposed to long-term violence and conflict has tended to focus on measurable effects of acute traumatic events, while attention to the pressures of their daily living context is relatively new. Using qualitative and quantitative data from a 2005 survey of all female family caretakers in 2 neighbouring Israeli-occupied West Bank villages (n = 820), we explored the associations of demographic, health-related and contextual factors with reported pressures and WHO-5 well-being index scores. The final model explained 17.8% of the variance with negative associations between health-related factors ("back-aches," "stomach aches" "psychological illness in the family") and family-related factors ("male head of household aggressive", "male head of household physically violent") and the WHO-5 well-being index scores. We found positive associations between socio-economic factors ("standard of living"; "number of rooms") and village-related factors ("residency in village A/B") and the WHO-5 well-being index score. Exploring the daily living context of villages A and B illuminated how the impact of historical and political events differed, even in villages that are geographically close. The paper lends support to calls for including politics and history in research on well-being in contexts of long-term violence and conflict.

Support groups for mothers of children with a handicap: a quantitative and qualitative study.

BACKGROUND: Since 2013, the community-based rehabilitation programme in the north of the West Bank has established nineteen support groups for mothers following a Multi-Family Approach (MFA), with technical support from the Institute of Community and Public Health (Birzeit University) and the War Trauma Foundation (Netherlands). The main aims of the programme are to improve the wellbeing of mothers who have children with a handicap, to build support networks between vulnerable families, and to counter problems associated with social isolation and stigma. The MFA intervention is monitored and evaluated through an approach called outcome mapping. METHODS: We used both quantitative and qualitative methods to evaluate mothers support groups in relation to outcomes and changes in behaviours, as reported by the mothers. We used a survey to investigate support group members' satisfaction with the intervention and changes in self-reported behaviour. Group interviews were done with mothers. We obtained approval from the University Research Ethics Committee and verbal informed consent from the mothers. FINDINGS: 51 members from seven support groups completed the survey. Four group interviews were done, including 12 mothers in total. 33 (64%) mothers reported that their participation in MFA groups leads to stress relief and having fun. 18 (36%) mothers reported that they exchanged experiences during the group sessions. Mothers attended the groups due to their desire to solve pressing practical problems that they experienced when caring for their children, to receive more community support, and to be able to leave the house to attend meetings deemed useful by their families. INTERPRETATION: The evaluation highlights the psychosocial value of support groups for mothers of children with a handicap. Having fun is an important factor ensuring regular group attendance and an indicator of improved wellbeing. Importantly, mothers were also able to experience stress relief by exchanging experiences and suggesting possible solutions in a caring and trusting environment. FUNDING: The British Academy.

The Multi-Family Approach to facilitate a family support network for Palestinian parents of children with a disability: a descriptive study.

BACKGROUND: Families with a child who has a disability have extra difficulties, particularly when services are hard to reach or less available. In a collaborative project, the Institute of Community and Public Health, the Palestinian community-based rehabilitation programme, and international non-governmental organisations cooperated to share and develop expertise and knowledge on increasing families' resilience through establishing family groups. This contribution focuses on the use of the Multi-Family Approach (MFA) in a Palestinian context. MFA is a family-oriented method provided in a group setting. The aim of this study was to investigate the feasibility of implementing the intervention and the experiences gained by introducing the MFA in the West Bank. METHODS: Parents taking the MFA approach learn from other parents by sharing experiences. Allowing parents to examine communalities and contrasts increases social support and parenting skills and decrease stress reactions. A high turnover of exercises and activities facilitate pleasant interactions. The basic principles of MFA are derived from both group and family interventions. Adjusting MFA entailed training of community-based rehabilitation teams (supervisors, field workers, and volunteers) through a learning-by-doing principle and employed a comparable strategy and structure to MFA. MFA was introduced and practiced, and early experiences were used to rehearse and elaborate. Training experiences were monitored and reflected upon within the team. A manual was written as a collaborative activity. No additional ethical approval was necessary. This project did not encompass the involvement, assessment, or monitoring of families or family members. The trainees participated on a voluntary base. FINDINGS: Qualitative analyses of the monitoring reports from the training sessions show that MFA is feasible for families with a child with a disability in the West Bank but that organisational, translational, and cultural adjustments are needed for MFA to be suitable within a Palestinian context. INTERPRETATION: MFA proved appropriate for the Palestinian setting. Most of the workers in the community-based rehabilitation programme and group participants were comfortable with the approach and adopted it within communities. FUNDING: Stichting Boo and Gieskes Strijbis Fonds.

Mental health, social distress and political oppression: the case of the occupied Palestinian territory.

This paper presents a brief history of Palestinian mental health care, a discussion of the current status of mental health and health services in the occupied Palestinian territory, and a critique of the biomedical Western-led discourse as it relates to the mental health needs of Palestinians. Medicalising distress and providing psychological therapies for Palestinians offer little in the way of alleviating the underlying causes of ongoing collective trauma. This paper emphasises the importance of separating clinical responses to mental illness from the public health response to mass political violation and distress. Palestinian academic research reframes the mental health paradigm utilising an approach based on the broader framework of social justice, quality of life, human rights and human security. Recognising social suffering as a public mental health issue requires a shift in the emphasis from narrow medical indicators, injury and illness to the lack of human security and human rights violations experienced by ordinary Palestinians. Such a change in perspective requires a parallel change in mental health policies from short-term emergency humanitarian aid to the development of a sustainable system of public mental health services, in combination with advocacy for human rights and the restoration of political, historical and moral justice.

Violence and adolescent mental health in the occupied Palestinian territory: a contextual approach.

During the past decade, the Institute of Community and Public Health at Birzeit University has focused on youth psychosocial mental health research with special attention given to protective factors and forms of resilience adopted by people coping with extraordinary and violent times. The authors take a critical view of the predominantly biomedical interventions adopted by humanitarian aid agencies and question the utility of therapeutic forms of interventions introduced by Western medicine. In a context of collective exposure to violence, individual healing methods based on one-to-one counselling generally have little effect. An alternative approach is proposed that views Palestinian mental health within the historical and political context of loss and injustice, while acknowledging the lack of human security and social justice as a determining factor. In building an argument for the development of psychosocial mental health interventions that are contextually appropriate to the Palestinian situation and collective in nature, the authors present an example of an intervention designed and developed in joint cooperation between a Palestinian academic institution and a Palestinian partner in the field.

Health as human security in the occupied Palestinian territory.

We describe the threats to survival, development, and wellbeing in the occupied Palestinian territory using human security as a framework. Palestinian security has deteriorated rapidly since 2000. More than 6000 Palestinians have been killed by the Israeli military, with more than 1300 killed in the Gaza Strip during 22 days of aerial and ground attacks ending in January, 2009. Israeli destruction and control of infrastructure has severely restricted fuel supplies and access to water and sanitation. Palestinians are tortured in prisons and humiliated at Israeli checkpoints. The separation wall and the checkpoints prevent access to work, family, sites of worship, and health-care facilities. Poverty rates have risen sharply, and almost half of Palestinians are dependent on food aid. Social cohesion, which has kept Palestinian society intact, including the health-care system, is now strained. More than US$9 billion in international aid have not promoted development because Palestinians do not have basic security. International efforts focused on prevention of modifiable causes of insecurity, reinvigoration of international norms, support of Palestinian social resilience and institutions that protect them from threats, and a political solution are needed to improve human security in the occupied Palestinian territory.