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InPsych 2011 | Vol 33

April | Issue 2

Psychology in current issues

Providing trauma therapy in the world’s longest war

Having spent most of his career working as a psychologist in Sydney, APS member Brett Stathis wanted to experience a new culture while putting his professional skills to good use. In 2009 he joined Médecins Sans Frontières and spent the next 10 months working as a psychologist in the West Bank of the Palestinian Territories where he found the principles of trauma therapy remain the same, even in situations that are worlds apart.

How would you describe the situation in the West Bank?

The city of Nablus in the West Bank is home to more than 100,000 Palestinians, many of whom have grown up in some of the world's oldest refugee camps and endured decades of psychological torment as a result of the conflict with Israel, occupation and fighting over settlements in the region.

To the average Australian, the Arab-Israeli conflict seems little more than occasional news reports about peace agreements and their inevitable breakdown. But what is forgotten in between news bulletins is the invisible impact of war: the long-term effect of psychological scars that burden entire communities.

Rising out of the desert about 60km north of Jerusalem, Nablus has for centuries changed hands between Christians, Muslims and Samaritans. In 1947 it was incorporated into the British Mandate of Palestine and remained Arab territory until the 1967 Six Day War with Israel. Today the city is administered by the Palestinian National Authority, although passage into the city remains under Israeli control.

How did you come to be working in the West Bank and what was your role?

I've always loved travel and about three years ago I began looking into how I could combine my interest in other cultures with my professional skills, where there was a need. In researching volunteer opportunities I came across Médecins Sans Frontières. It was the best match for my personal philosophies and skills, and after going through the application process, I was offered this unique opportunity to spend 10 months in the West Bank during 2009-10.

Médecins Sans Frontières is one of the largest international providers of emergency medical assistance. Founded by a small group of French doctors and journalists, the organisation's philosophy centres around impartiality and raising public awareness to humanitarian catastrophes, often speaking out when others can't or won't. It runs projects in some of the most desperate corners of the world, often in wars and disasters the international community has long forgotten or ignored.

Médecins Sans Frontières is one of the only international medical organisations working in the West Bank to provide psychological, medical and social care. In Nablus there were about 15 team members, consisting mostly of local psychologists with three expatriates - two psychologists (including myself) and a ‘field' or project coordinator - providing additional support and mentoring. The team conducts about 55 consultations per week with men, women and children in and around the city, surrounding villages and refugee camps, as well as in the main office.

What were your first thoughts when you arrived in Nablus?

It was a case of sensory overload. Everything was different and it was a challenge trying to take it all in - the sights, sounds, smells, and of course, the rules and procedures in place for our safety. The first few weeks were exhausting.

Paradoxically, the other major impression was of unexpected similarities between this new environment and home - the characters in the team I was working with, the need to connect on a personal level with patients in their homes, and the use of those same professional skills, albeit in unfamiliar circumstances.

How did your training and experience as a psychologist prepare you for working in this volatile region?

Working for years in trauma therapy had equipped me with the clinical knowledge and skills to handle unexpected cases, but I wasn't really prepared for the magnitude or depth of psychological trauma that my patients have experienced.

The first word that comes to mind in describing the psychological situation for many of our patients is ‘disaster'. To be stripped of your home, your land, basic rights, any sense of security, and feeling that the rest of the world supports the army occupying your country, leads to feelings of hopelessness and helplessness. It's well known that such feelings place individuals at a very high risk for clinical depression, and the same goes for the population.

The occupation and intra-Palestinian conflict, combined with a lack of support from outside, has caused terrible economic and social conditions. Families have been forced to live in refugee camps for 60 years and despite many gaining tertiary qualifications, the jobs just aren't there. The presence of spies for both the Palestinian regime and the occupying forces make paranoia a survival mechanism, and innocent civilians fall victim to both Israeli and Palestinian forces involved in the complex power struggle.

In places where war or suffering has continued for years, the need for counselling services is paramount. But even if the country has resumed functioning, these services may not be available as public funds are prioritised to development or primary health care.

What were the common problems you and the team were treating?

Surviving day to day in such an intense environment manifests differently from one person to the next. Bed-wetting was the most common problem we treated in children, along with recurrent nightmares and fear of leaving their homes. Such physical and psychological symptoms were usually triggered by witnessing soldiers break into their homes at night, seeing their father or uncle being arrested or hearing about others' experiences.

Sadly, domestic violence is also common in these environments because men don't know how to communicate their fear or physically manage their frustration, and take it out on their wives and children. However, incidences are decreasing as more people utilise psychology services that focus on giving men coping strategies.

There was a particular man I worked with who had been imprisoned and continued suffering for years after. He improved during therapy, but several months after therapy had ceased he was re-arrested. Afterwards he said that he remembered our sessions while in prison which helped him to cope and made re-adjusting to home much easier than on the previous occasion. He had stopped beating his wife and children, and adopted more effective coping strategies. This benefited his immediate family as well as the broader community, as men's behaviour was often influenced by their peers.

What was the hardest part of your time in the West Bank?

This can be different for each person. For some colleagues it was missing loved ones and comforts at home. For others, it's the confrontational nature of the humanitarian situation they are in.

For me it is difficult to nominate such a difficulty as I appreciated the opportunity to experience a different lifestyle for a relatively short time, knowing I'd be returning home soon enough. It's hard being aware that you'll be leaving while the people you're working with will have to endure such demoralising and dangerous conditions probably for the rest of their lives.

I was very fortunate not to have overly negative experiences but rather just frustrating incidents. Once I was denied re-entry at the Israeli border and had to wait almost two weeks in Jordan before my visa could be worked out, along with hours of waiting and questioning at the borders. Another time we had to terminate a therapy session with a family because settlers were attacking the village. Fortunately the family understood, survived yet another attack and therapy continued the following week.

It was also heartbreaking to see people elated over receiving their permission to travel through a checkpoint to visit relatives - such circumstances would be difficult to imagine back home.

How did you find working with local staff who may have had different training to you?

Local staff are the backbone of these community-based projects and act as interpreters, guides, teachers, friends and students to the expatriates. Building relationships with the national staff and other locals was certainly a highlight. The team would go out of their way to do anything they could to make it a positive experience.

Despite each of them having their own history of trauma living on the West Bank, their optimism, desire to make a difference for the beneficiaries of our service, and sense of humour were unforgettable. The relationships I developed helped me to keep focused and remain determined to make a difference. The most important person to get along well with is your translator, as you spend most of your time together, and he or she is indispensible for carrying out your duties. My translator and I became instant friends, having similar views on how to approach our varied patients, and was a guide to the culture.

How would you describe your overall experience in the West Bank, and do you want to do more humanitarian work?

Ultimately, it was both professionally and personally rewarding. Knowing that my professional skills were making a difference to people who really needed help was humbling. That's not to say my clients in Sydney are less worthy, but these were people who are otherwise neglected by the global community.

While on placement I met some other expatriates from various NGOs who move directly from one placement to another. Although this approach does not feel right for me, I would like to do another assignment after a year or so. This experience was a test to see whether it would open a new path for me and it has, but I also think it's important to have a home and maintain relationships and career networks at home.

The Middle East has always appealed to me, but I think next time I'll try to experience a different environment, perhaps in Africa.

Thanks to Katie Butt for conducting this interview.


Disclaimer: Published in InPsych on April 2011. The APS aims to ensure that information published in InPsych is current and accurate at the time of publication. Changes after publication may affect the accuracy of this information. Readers are responsible for ascertaining the currency and completeness of information they rely on, which is particularly important for government initiatives, legislation or best-practice principles which are open to amendment. The information provided in InPsych does not replace obtaining appropriate professional and/or legal advice.