An Najah National University Faculty of Graduate Studies PSYCHOLOGICAL TRAUMA EXPERIENCE AMONG PALESTINIANS DUE TO THE ISRELI OCCUPATION By Yasmeen Khaled Mohammed Matani Supervisor Dr. Mohammad Marie This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Clinical Psychology, Faculty of Graduate Studies, An-Najah National University, Nablus, Palestine. 2024 ii PSYCHOLOGICAL TRAUMA EXPERIENCE AMONG PALESTINIANS DUE TO THE ISRELI OCCUPATION By Yasmeen Khaled Mohammed Matani This Thesis was defended successfully on 27/11/2024 and approved by: iii Dedication I would like to dedicate this thesis to all the people who are taking part in completing it. To begin with, I extent my deepest gratitude and thanks to my supervisor Dr. Mohammad Meri. Also, I would like to thank Doctors Without Borders, who funded my thesis. This scholarship helped me complete my graduate studies and facilitated the conducting of research. Finally, I extend my thanks to all my professors at An-Najah National University. Yasmeen Matani iv Acknowledgments To begin with, I thank Allah Almighty for assisting me in completing this thesis. Consequently, it is dedicated to everyone who supported me with their advice, love and care, including my family and friends. Yasmeen Matani v Declaration I, the undersigned, declare that I submitted the thesis entitled: PSYCHOLOGICAL TRAUMA EXPERIENCE AMONG PALESTINIANS DUE TO THE ISRELI OCCUPATION I declare that the work provided in this thesis, unless otherwise referenced, is the researcher’s own work, and has not been submitted elsewhere for any other degree or qualification. Student's Name Yasmeen Khaled Mohammed Matani Signature: Date: 27/11/2024 vi Table of Contents Dedication ........................................................................................................................ iii Acknowledgments ........................................................................................................... iv Declaration........................................................................................................................ v Table of Contents ............................................................................................................ vi List of Appendices ......................................................................................................... viii Abstract ............................................................................................................................ ix Chapter One: Introduction an Literature Review ............................................................. 1 1.1 Background ................................................................................................................. 1 1.2 Statement of the Problem ........................................................................................... 5 1.3 Objectives of the study ............................................................................................... 6 1.4 Questions of the Study ................................................................................................ 7 1.5 Literature Review ....................................................................................................... 7 1.6 Psychological Impact of Contemporary Warfare ....................................................... 7 1.7 Conclusion ................................................................................................................ 21 Chapter Two: Methodology ........................................................................................... 22 2.1 Research Design ....................................................................................................... 22 2.2 Sampling strategy ..................................................................................................... 22 2.3 Ethical, Access, and Political Consideration ............................................................ 23 2.3.1 Ethical approval ..................................................................................................... 23 2.3.2 Inviting participants to participate ......................................................................... 24 2.4 Data Collection Tools ............................................................................................... 25 2.4.1 Interview process ................................................................................................... 26 2.5 Data Analysis ............................................................................................................ 28 2.5.1 Data Analysis Process ........................................................................................... 28 2.6 Conclusion ................................................................................................................ 30 Chapter Three: Results ................................................................................................... 31 3.1 Introduction .............................................................................................................. 31 3.2 First Theme: Traumatic Events ................................................................................ 32 3.2.1 Direct Exposure to Harm ...................................................................................... 32 3.2.2 Relatives Being Harmed ....................................................................................... 36 3.2.3 Lack of Basic Resources........................................................................................ 40 3.3 The Second Theme ................................................................................................... 43 3.3.1 Emotional Responses ............................................................................................. 44 vii 3.3.2 Impact on the Physical Aspect............................................................................... 45 3.3.3 Impact on the Cognitive Aspect ............................................................................ 47 3.3.4 Impact on the Behavioral Aspect........................................................................... 51 3.3.5 Impact on the Spiritual Aspects ............................................................................. 52 3.4 The Third Theme ...................................................................................................... 53 3.4.1 Impact on the Emotional Aspect ........................................................................... 53 3.4.2 Impact on the Cognitive Aspect ............................................................................ 68 3.4.3 Impact on the Behavioral Aspect........................................................................... 71 3.4.4 Impact on the Physical Aspect............................................................................... 76 3.4.5 Impact on the Spiritual Aspects ............................................................................. 77 3.4.6 Impact on the Material Aspect............................................................................... 78 3.5 The Fourth Theme .................................................................................................... 78 3.5.1 Mechanisms in the Spiritual Domain .................................................................... 79 3.5.2 Mechanisms in the Behavioral Domain................................................................. 81 3.5.3 Use of Medical Substances .................................................................................... 82 3.5.4 Social Aspect ......................................................................................................... 82 3.5.5 Treating Trauma with Trauma ............................................................................... 85 3.5.6 Surrender and Submission ..................................................................................... 85 Chapter Four: Discussion and Recomendation .............................................................. 87 4.1 Introduction .............................................................................................................. 87 4.2 Discussion ................................................................................................................. 87 4.3 Recommendations .................................................................................................... 92 4.4 Suggestions ............................................................................................................... 93 References ...................................................................................................................... 94 Appendices ................................................................................................................... 101 ب ............................................................................................................................... الملخص viii List of Appendices Appendix A: Questioaurre ............................................................................................ 101 Appendix B: The main questions of the interview ....................................................... 102 Appendix C: IBR Approval Letter ............................................................................... 103 Appendix D: Demographic information ....................................................................... 104 ix PSYCHOLOGICAL TRAUMA EXPERIENCE AMONG PALESTINIANS DUE TO THE ISRELI OCCUPATION By Yasmeen Khaled Mohammed Matani Supervisor Dr. Mohammad Marie Abstract Background: Post-traumatic stress is a common problem among Palestinians in the Gaza Strip and the West Bank, especially Tulkarm. Aim: The study aims to identify the causes of psychological trauma among Palestinians as a result of the occupation, their first reactions, the impact of the trauma on them, the mechanisms used to cope with their trauma, and the differences between males and females in this regard. Method: This study used the mixed method and thematic analysis to achieve its aims. The fieldwork procedures were implemented during the period between January 2024 AD and February 2024 AD, as the study population included adults 18 years of age and above in both Gaza and Tulkarm. After the target group for this study was chosen, the study sample was determined, which, in its final form, reached 32 adults, six women and 27 men. To reach the sample, the researcher followed the purposive sampling method. The interview consisted of 4 basic questions and sub-questions according to the situation. Results: Results showed with regard to the causes of trauma that three basic factors shaped the symptoms of post-traumatic stress among Palestinians as a result of the occupation. The factors consist of direct exposure to harm, exposure of relatives to harm, and a lack of basic resources for life. Each of these factors includes many sub-factors. Conclusion: Finally, recommendations were made to those working in the field of mental health to help those affected enjoy better mental health. Semi-structured interviews were used as a basic tool for collecting data. Keywords: PTSD; Israeli occupation; psychological trauma; the West Bank. 1 Chapter One Introduction an Literature Review 1.1 Background Psychological trauma is an event or a condition where a person is left feeling their or another person’s life is in danger, fearing for his/her sanity or fearing for their life being not able to do anything to change the condition (Yıldırım, et al., 2023). In other words, the person could also feel deathly, insane, maimed, or a total breakdown. The person may be wiped out mentally, emotionally, and physically. The conditions under which the event occurred often include misuse of power, betrayal of trust, entrapment, helplessness, pain, confusion, and loss. It is significant to note that there are many types of traumas and, hence, the people who undergo them are pretty different from one another. Despite the types of stress and victims involved, researchers have identified generalizable patterns and response mechanisms that offer beneficial frameworks for understanding trauma (Neuner, 2022). Ozturk, Akis, Derin, & Erdogan (2023) differentiated between single-incident crisis events and recurring traumatic experiences. There are several common kinds of horrifying experiences, such as earthquakes, storms, floods, volcanoes, and other natural catastrophes, such as car and plane wrecks, chemical spills, downed power lines, and nuclear meltdowns. These affect some people’s traumatic reactions. A study by Veronese, Pepe, Alzaanin, & Shoman, (2020) argued that the workers in the Palestinian health sector have an extreme risk of psychological consequences under conditions of violence. So, they need to protect their mental health by mobilizing sources of resistance and resilience, such as a sense of coherence, subjective well-being, and growth. Marie, SaadAdeen, & Battat (2020) point out that Palestinians are extremely at high risk of anxiety, turmoil, and PTSD awaited to without respite exposure to political brutality and stretched displacement. Moreover, the result of their study showed that anxiety turmoil and PTSD are some of the most common mental disorders in Palestine. For example, research has provided evidence that the psychological sequel of traumatic events is well-rooted in the recognition. The individuals subjected to traumatic events associated with military and political conflict experience dire psychological consequences (Baker & Shalhoub-Kevorkian, 1999). The mechanism used in assessing 2 post-traumatic stress disorder has been adopted as a new diagnosis in ICD-11. The disorder is divided into several types, the most severe of which is complex post-traumatic stress disorder, in which people are exposed to continuous acts of violence. It is noteworthy that post-traumatic stress disorder is prevalent at a rate of 1-8% of the population and may reach 50% in health sectors concerned with mental and psychological health. The study concluded that progress had been made in assessing, diagnosing, and distinguishing between post-traumatic stress disorder and borderline personality disorder (Maercker, et al., 2022). Most individuals do not get PTSD after a horrific event, according to the National Center for PTSD. Indeed, only about 6 out of every 100 people in the US, or around 6% of the population, will get PTSD in their entire life. Many persons who have PTSD and receive therapy end up recovering and no longer fitting the diagnostic standard for the medical problem. That means this figure includes any person who has ever had PTSD, regardless of whether the symptoms went away. Every year, 5% of Americans have PTSD. In 2020, 13 million individuals had PTSD all over the United States (Schnurr, et al., 2022). PTSD is more common in women than in men. Approximately 8 out of 100 women and 4 out of 100 men will experience PTSD at some point in their lives. This is partly because women are more likely than males to endure the kinds of traumatic situations that include sexual assault (Schnurr, et al., 2022). According to WHO (2006), 32% of teenagers between the ages of 10 and 19 experience post-traumatic symptoms. (In the Bethlehem area of the West Bank, 42% of children experience mental health issues. (emotional and behavioral). Hence, Ombok (2011) showed that 38.1% of participants experience post- traumatic symptoms, whereas 3.1% experience acute stress. 93% of the children surveyed reported feeling uneasy and fearful, not just for themselves but also for their families, according to a psychological examination done by Save the Children in collaboration with the Secretariat of the National Plan. In addition, the International Journal of Mental Health Systems claims that the regional mental health and counselling services network identified 1369 patients with a patient age of more than one year between 2005 and 2008. Each was clinically evaluated using a semi-structured interview based on the DSM-IV-TR criteria. In 1254 individuals, PTSD was reported by 23.2%. Children under the age of 15 were more likely to have PTSD than 3 adults, with depression being the most common symptom among adults. Being present when a murder or other physical assault occurred, as well as receiving threats, were significant risk factors for developing PTSD in children under the age of 15. Compared to the typical person worldwide and the nations around them, Palestinians are far more prone to experience PTSD. PTSD affects 5% and 3.6% of the world's population. The prevalence of severe PTSD in children living in the Gaza Strip is 32.7% (Espié, Gaboulaud, & Baubet, 2009). When one faces conflict in Palestine, a child is likely to contribute a traumatic aspect to the plays, dreams, storytelling, listening to music, and other activities. In addition, the effects of a child being close to war can also be evidenced by their avoidance of emotional responses. Therefore, it implies disparate forms of destructive behaviours and a general lack of interest in life. Descriptive studies on children’s psychological responses to wartime stress have been going on for a very long time in many areas around the world (Catani, 2018). Since the British assumed control of Palestine in 1917, conflict and hardship have defined Palestinian existence. While residents of the West Bank and Gaza have long struggled, circumstances in Gaza have been especially dire over the past decade. Israel's air, sea, and land blockade of Gaza has strangled economic development and entrenched pervasive poverty and widespread food insecurity among Palestinians. Moreover, it has inflicted deep and lasting trauma, particularly on Gaza's children. For Palestinian youth, wars are a recurring reality that continuously tests their ability to cope with trauma. The children of Gaza have borne the brunt of one military operation after another, without respite between the First Intifada of 1987, the Second Intifada in 2000, Operation Cast Lead in 2008, Operation Pillar of Defense in 2012, Operation Protective Edge in 2014, and last year's Guardian of the Walls, Israel's most recent assault on Gaza. Living through so many conflicts has taken a severe toll on Palestinian youth (Farajallah, 2022). The threat of lethal force and grievous injury, coupled with sexual harassment, affect the lifestyle of all children. Events of such a traumatic nature often remain seared in one's memory until life's conclusion. For over three generations, the people of Gaza have endured a calamitous existence in a perpetual state of distress. Studies indicate that the prolonged effects on the total populace have left the Palestinian people psychologically 4 traumatized. Palestinian youth suffer immensely due to the antagonism that has engulfed their region for numerous years, depriving a generation of the carefree times of childhood. Farajallah (2022) revealed the ongoing struggles that Palestinian youth continue facing each day as a result of lifelong exposure to violence and conflict. Generations of Palestinian children have been forced to come of age under the cloud of never-ending hostilities. The prevalence of Post Traumatic Stress Disorders (PTSD) comorbid with Major Depressive Episodes (MDE) was explored in Palestine in the aftermath of the second intifada. The sample of the study consisted of 916 Palestinians to test the use of DSM IV criteria for PTSD and the SCID I modules. The result shows evidence that the prevalence of chronic PTSD is comorbid with lifetime MDE and chronic PTSD. In addition, Higher numbers of refugees were found to suffer from PTSD comorbid with MDE (Madianos, Sarhan, & Koukia, 2011). Previous studies have emphasized, such as Agbaria, et al. (2021) study that explores the prevalence of post-traumatic stress disorder (PTSD) in Palestinian children and adolescents exposed to political violence. The results of the experiment found clear support for the PTSD prevalence did not differ according to the region in Palestine and tended to decrease after including only studies using a representative sample (p<0.001) and among those with low risk of bias (p<0.001). Where The pooled prevalence of PTSD was 36% (95%, 30–41%; 98.6%) and ranged from 6% to 70%; also, they identified a high prevalence of PTSD among Palestinian children and adolescents exposed to political violence. Violent political conflict, wars, and conflicts have had a devastating impact on the physical and mental health of children in Palestine, Syria, and Iraq. Many have been killed or injured. Many have been displaced, including 2.5 million Syrian child refugees. Palestinian children trapped in the Gaza Strip cannot even escape to safety because of wars and conflicts. The impact of war means that little attention has been paid to supporting longer-term mental health. The results cast a new light on a concerted effort needed among policymakers, humanitarian agencies, and health services in the region to increase resilience, prevent the escalation of mental and physical health problems, and 5 advocate for security and health (Samara, Hammuda, Vostanis, El-Khodary, & Al-Dewik, 2020). 1.2 Statement of the Problem Since the accounts of this accident have been passed down from generation to generation from the beginning of the occupation until now, the struggle in Palestine is a horrific occurrence that Arabs have been interested in for years. Only in the past ten years have numerous instances of widespread trauma have complicated repercussions on the person (Spytska, 2023; Maercker, et al., 2022). According to Yehuda et al. (2015), post-traumatic stress disorder (PTSD) can be defined as a series of violent symptoms that alter an individual's equilibrium, and their perspective of themselves and the world around them is frequently linked to conflicts and disasters. This traumatic incident occupies a significant portion of our memory, disturbs our consciousness, and warps the lens through which we perceive the world, leading to unwarranted worry. Trauma results from our minds' failure to process events that endanger our existence and those that cause disorder in the outside world; not only can these two halves of the self- split apart, but they can also become isolated from their surroundings. Due to recalling the specifics of that terrible occurrence, fear of it happening again, and reproach of everything associated with it, this separation becomes a harsh battle with their memories and dreams. However, the history of trauma in communities or among individuals reveals to us that these indications and symptoms are passed down to succeeding generations rather than just affecting the one who encounters them (Storozhuk, et al., 2022). As noted by Noor (2020), Post-traumatic stress disorder (PTSD) due to war and conflict results in a pattern of symptoms that include a delayed response to an acute, life- threatening, stressful event or situation. Individuals are usually exposed to multiple traumatic experiences due to conflicts. For example, the war that took place in the summer of 2014, where people faced many stressors during the war, including personal threats to their lives and families and the destruction of their homes. This study aimed to assess the level of PTSD and examine the relationship between exposure to war stress and PTSD symptoms during the Israeli war on the Gaza Strip in 2014. The results showed that 6 (92.6%) of the participants, which means that they had severe PTSD symptoms. Thus, the total scores ranged from 25.03 to 78.0, with a mean of 53.16. Individuals living in a conflict area suffered from severe PTSD symptoms four years after the 2014 war in the Gaza Strip. The concern is that such high rates of PTSD prevalence will have negative consequences in terms of psychological and social problems and disorders. The 2014 conflict caused significant trauma to Palestinians. Many suffered from injuries, lost homes, and faced displacement. This has led to serious mental health problems that continued for years. The researchers anticipate that insights gleaned will offer practical approaches for addressing issues exacerbating stress. The study findings also aim to provide practical insights for mental health professionals, clinicians, and social advocates in Palestine to better understand and address trauma within their communities. By gaining a deeper understanding of causative pressures and their interplay, mental health professionals can devise workable strategies for building resilience and fostering recovery among trauma-affected Palestinians in their communities. 1.3 Objectives of the study - To examine the mental anguish inflicted upon Palestinians as a result of the occupation. - To explore the primary triggers that give rise to psychological trauma in Palestine. - To determine whether distinctions exist in contributing factors between males and females, along with the reasons for any disparities or their absence. - To evaluate the role of Palestinian culture and context with mental distress. - To investigate potential therapeutic interventions and reasons for the escalation of psychological trauma in Palestine over time. - To identify measures to preempt additional psychological trauma afflicting Palestinians under occupation. - To formulate suitable recommendations. 7 1.4 Questions of the Study This study aims to answer the following questions: 1. What are the most prevalent causes of psychological trauma in Palestine? 2. How do the responses of those who have experienced occupational trauma differ? 3. How does psychological trauma affect Palestinian’s daily lives? 4. What are the strategies that Palestinians use to mitigate the effects of their trauma? 1.5 Literature Review This study encompassed several distinct yet interconnected phases. First and foremost, the scholar meticulously examined the complete written works within the assemblage, absorbing both minutiae and macro themes. Secondly, relying solely on headings and summaries, the scholar surveyed potentially pertinent publications. Having identified several candidates for deeper inspection, the scholars thoroughly read and analyzed said full texts, considering content and claims across various disciplines within PubMed, Direct Science, Google Scholar, SAGE Journal, Plos One, Springer Link, and IAAP. Throughout, the scholar remained faithful to texts authored in the English language. The study analyzed and examined the reliability and validity of relevant research studies using statistical experimental methods. Many factors were considered, such as the tools used in these studies, the objectives of each, the target samples, the methods of data collection, the limitations of these studies, and finally, the ethical positions of these studies. 1.6 Psychological Impact of Contemporary Warfare Palestinians have suffered increasing levels of war trauma with Israel, especially children. They have been exposed to danger and violence due to the ongoing conflicts. They have become a specific group in society, as most of them suffer from the psychological impact of the ongoing war, which creates serious psychological problems for them. This study aims to analyze how war and post-war trauma unfolds among Palestinians, especially children. The study reviews the psychological effects that these wars have left on 8 individuals and their repercussions on their mental health and society (Abudayya, Bruaset, Nyhus , Aburukba, & Tofthagen, 2023). In wartime, one attempts to escape all perils with all his strength and remain alive; thus, some are in a state of shock and are terrified and anxious to the limit that they cry. On the other hand, some depend on which is a psychological defence mechanism of living in a seminatural state after the occurrence of trauma. The risk of developing PTSD, depression, and anxiety increases as people are exposed to more traumatic events. Some violent armed conflicts may lead both armed groups and children to be separated from their families and communities. These children, who would also be called “child soldiers,” may either see or be forced to kill people or experience and be victims of other traumatic acts. Children who experience the above as former child soldiers may likely have both physical and psychological injuries, as most of their families could reject them back after the war (Boukari, et al., 2024). There are situations where the trauma can be massive and protracted, described as Type II trauma. For illustration, situations like these are relatively common in the world today. Wars today are virtually all ‘low-intensity’ conflicts fought by and in poor countries. It has been estimated that there have been over one hundred and fifty such wars since 1945, accounting for 90% of all casualties. As (Summerfield, 1997) puts it, if there is a common denominator, it is the overwhelming centrality of the use of terror as a means and state policy of social control, and the principal, if not exclusive, target became population, not territory its the central element of contemporary (‘low-intensity) warfare was psychological. Atrocities, civilian massacres, reprisals, bombing, shelling, mass displacements, disappearances, and torture were the rule. The effects on mental health and social, economic, cultural, and other costs can be staggering. Research Studies on War-Related Trauma and PTSD Trauma occurs when humans are subjected to unexpected and sudden occurrences. The resulting shock may be the root cause of psychological, physical, emotional, and social problems. Again, natural phenomena like earthquakes and unnatural disasters like wars, domestic abuse, and forced migration can present human trauma. The Palestinian population has been subjected to war-related activities for a long time; hence, the people 9 are prone to psychological trauma and post-traumatic stress disorder. These studies center on war-related trauma, especially among Palestinians (Fullerton & Ursano, 2009). Many studies tackled the issue of PTSD. Nickerson, Priebe, Bryant, & Morina (2014) used structural equation modeling to investigate the influence of interpersonal sensitivity on PTSD posttraumatic stress disorder symptoms, depression symptoms, and anger responses after war trauma exposure. Researchers divided participants into two groups based on their experience with the war, whether they were exposed to it or served as civilians. Three thousand three hundred thirteen survivors of the war in the former Yugoslavia were located and selected. Personal sensitivity, service exposure, PTSD, and other factors such as depressive symptoms and anger responses were among the most important things that participants were asked. Therefore, structural equation modeling analyses were used to determine whether there was a statistical association. It was found that there was a statistical association between PTSD and depressive symptoms partially due to personal sensitivity. The findings showed that interpersonal sensitivity fully mediated the connection between trauma and rage reactions. Interpersonal sensitivity is an important mechanism in developing psychological problems after trauma. PTSD is a highly stigmatized condition among veterans who often avoid seeking help for their mental health needs. The stigma acts as a main barrier that prevents veterans from using available health services. Yet research has not explored how receiving service-connected disability status affects veterans' experiences of stigma from other veterans. Hooyer (2022) investigates two interrelated questions. The first question pertained to how posttraumatic stress-stricken combatants were stigmatized in the process of care provision by utilizing the Veterans Affairs resources. The second question that the researcher addressed is what the effect of linking a diagnosis of posttraumatic stress disorder to disability benefits was. The researcher discovered that stigma existed in two interrelated terrains. They include the structural element of the disability claims process of the Veterans Affairs and the individual or face-to-face terrain of interactions with the providers of the Veterans Affairs. 10 According to the findings of the study on veterans’ narratives, the disability claims process or the multiple repetitions of the personal traumas and impressions of the institutional stigma, which implied that the person was malingering, exacerbated the symptoms. This operation affected the Veterans Affairs’ first-time users, discouraging them from obtaining the required help, and did not affect the subjects’ operations once the treatment began. The veterans sought the process of gaining the disability payment despite the stigmatization and the commodification of their sufferings to the compare- commodity form of disabilities and diagnostic screen, and their awards were perceived as losses and donations freely given by volunteers. Weierstall, Huth, Knecht, Nandi, & Elbert (2012) conducted a study on Fifty German veterans to explore the long-term association between trauma-related illness and aggressiveness. The sample was (age: Median = 86.7, Standard Deviation = 2.8). In their study, wartime hostility was assessed using the Appetitive Aggression subscale of the APP-D. To evaluate present and lifetime PTSD symptoms, the PSS-I questionnaire was administered. It was found through linear regression analysis, accounting for 31% of the variance, that veterans with higher AAS scores reported lower PSS-I symptom severity throughout their entire post-war lives (β =0.31, p =0.014). The effect size and statistical power were adequate (η = 0.51, ρ = 0.99). These results also applied to current PTSD (β =0.27, p = 0.030). Thus, appetitive aggression is a resilience factor against the negative, long-lasting effects of battlefield experiences. This has implications for practices that could help reduce trauma-related mental anguish within the Peace Corps as well as create more suitable homecoming ceremonies for veterans. Garza & Jovanovic (2017) surveyed one thousand twenty-two adults in Timor-Leste over six years to monitor changes in mental health after experiences with communal clashes and domestic brutality. Those studied had been exposed to wide-scale strife during Indonesia's rule from 1975 to 1999, in 2004 when independence was achieved, and later in 2010-2011 after an interval of turmoil within the nation. The sampling comprised six hundred persons from rural hamlets and four hundred twenty-two from urban areas to represent conditions in both settings. All grownups in the designated rural towns and urban locations were included in the census-like examination. Complex sentences with variations in structure and length were used to convey the information while aiming for a degree of perplexity and burstiness resembling natural human writing. 11 The survey includes questions about PTSD, acute distress, traumatic incidents, poverty, ongoing war, and injustice. One thousand two hundred forty-seven of the one thousand five hundred fifty-four invited people completed the baseline survey, and one thousand thirty-eight were contacted. The study included one thousand twenty-two participants with sufficient data at baseline and follow-up. Posttraumatic stress disorder, increasing from twenty-three of one thousand twenty-two people to one hundred seventy-one of one thousand twenty-two people. As well, severe distress, increasing from fifty-seven of one thousand twenty-two people to one hundred sixty-two of one thousand twenty-two people, was linked to disability at the follow-up. Recent literature has focused on biological factors that may increase girls’ risk and that influence childhood and adolescence PTSD (Garza & Jovanovic, 2017). Over 60% of children and young people suffer from traumatic events, with many developing PTSD. Yes, there is increasing awareness that PTSD presents differently by gender, with women developing the disease at two times the rate as men. While sex differences in symptoms and their neurobiological substrates seem to emerge during adolescence, it remains unclear what biological mechanisms are critical for developing these sex differences. A recent study by Fan, Cheung, & Su (2024), aimed to assess the mental health burden of the population, health care needs, and associated risk factors in Myanmar. Myanmar is facing several crises, the most important of which is mass conflict. The study highlights the risks that individuals face due to conflicts, which lead to many psychological problems, the most important of which is post-traumatic stress disorder. A random sample of 1038 adults was targeted during the ongoing conflict and the high incidence of SARS- CoV-2. Probable post-traumatic stress disorder (PTSD) was assessed using the Post- Traumatic Stress Disorder Checklist to show the reality and suffering experienced by individuals exposed to mass persecution and conflict. Multivariate logistic regression models were used based on the mental health burden and healthcare-seeking patterns. The results showed that the proportion of adults at risk of developing a mental disorder was (34.9%, 95% confidence interval 32.0-37.7). Probable PTSD, depression, and anxiety were also reported at 8.1% (6.6–9.7), 14.3% (12.0–16.6), and 22.2% (19.7–24.7), respectively. The probable PTSD findings were attributed to political stress. 12 According to Sarhan et al. (2024) their study was conducted to measure the prevalence of PTSD among Palestinian citizens whose homes were demolished. The Event Impact Scale-Revised (IES-R) was used to assess participants' levels of PTSD. The study results confirmed that most individuals who are exposed to PTSD suffer from serious psychological consequences such as depression, stress, and constant anxiety, which affects their way of life, and instability, fear, and constant panic of repeating any experience becomes essential in their lives, whether children or family, which affects society as a whole. Studies in Arabic Countries Since 2013, Syrian refugees faced major human rights violations. They have experienced trauma, death, and loss of their homes and belongings. The process of moving to a new country also creates mental health problems for many refugees (Renner, et al., 2021). Researchers investigated factors connected to symptoms of post-traumatic stress. The study used information collected at the outset of the "Sanadak" randomized controlled trial. One hundred thirty-three adult Syrians seeking refuge participated in the research. A wide-ranging survey explored participants' backgrounds and what they confronted before and after arriving in Germany. Tests evaluated post-traumatic stress symptoms using the PDS-5, depression with the PHQ-9, somatization using the PHQ-15, anxiety via the GAD-7, general self-efficacy with the GSE scale, religious views applying the Z- scale, social assistance through the ESSI questionnaire and views about mental health stigma using the SSMISSF. Statistical models were developed to anticipate various mental health consequences based on respondents' replies. The study findings confirmed that measures to promote mental health in Syrian refugees with PTSD. Financial security and specialized psychosocial programs that address the stigma associated with mental health are expected to be (Renner, et al., 2021). Research on Arab populations shows that PTSD and major depression are the most common mental health problems from war and conflict (Al-Ghzawi, AlBashtawy, Saleh Nasser, & Alzoghaibi, 2014). Studies found that between 30% and 60% of Syrian refugees had PTSD symptoms (Mahmood, Ibrahim, Goessmann, Ismail, & Neuner, 2019; Tinghög, et al., 2017; Kazour, et al., 2016; Alpak, et al., 2015). Among Palestinians who faced long-term political violence, studies found that 36% had PTSD, with rates between 13 6% and 70% (Agbaria, et al., 2021). These PTSD rates were higher compared to other populations who experienced conflict (Steel, et al., 2009). The tests used in these studies were not appropriately checked for Arab communities. This created problems because war experiences in the Middle East are different, especially with ongoing conflicts (Kazour, et al., 2016). Most studies only counted how many people had PTSD without looking at how trauma affected these communities in different ways (Mahmood, Ibrahim, Goessmann, Ismail, & Neuner, 2019; Tinghög, et al., 2017; Kazour, et al., 2016; Alpak, et al., 2015). Studies in Palestine Most early studies, as well as current work, focus on the prolonged turmoil and conflict in Palestine that have left scars on the youngest generation. Examination of Gazan youth uncovered trauma's toll. A random cross-section of hundred thirty-seven children from throughout Gaza, ages ten to eighteen, volunteered their experiences. Participants candidly detailed encounters with violence on the Checklist of Traumatic Events. Signs of post-traumatic stress were also self-reported utilizing the Symptoms of Post-Traumatic Stress Disorder Scale. Each youth further disclosed aspects of character and behavior through the lens of the Personality Assessment Questionnaire. Their collective insights provided troubling evidence of conflict's corrosive impact on development. Despite adversity, these children shared their stories—voices to the hardships of growing up amid strife (Altawil, Nel, Asker, Samara, & Harrold, 2008). This study mentioned that every Palestinian youth had receipts of no fewer than three series of commonplace traumatic events. These included hearing the sound of explosions or bombs 97%, seeing a martyr's funeral 85%, and seeing military aircraft, tanks or artillery bombardment 84%. 98% of kids had been humiliated by themselves or a relative. One of the most significant conclusions of this research was the rate of post-traumatic stress disorder diagnosis amongst children — 41%. (PTSD). Of the 41% of children with PTSD, twenty percent 57,606 had severe PTSD, twenty-two percent 67,531 had moderate, and eighty percent (180,058) had mild. Palestinian children are 53.3% 742,200 of all Palestinians residing in Gaza (Altawil, Nel, Asker, Samara, & Harrold, 2008). There are one million four hundred thousand people in the Gaza Strip. Palestinian Centre of Statistics (2006) states that three hundred five thousand one hundred ninety-five children in the Gaza Strip need immediate psychological, social, and health care in the 14 prevention, counseling, rehabilitation, and treatment. Ultimately, exposure to repetitive traumatic events leads to more PTSD symptoms in Palestinian youngsters in the Gaza Strip. The most common types of PTSD in children were cognitive symptoms, which affected 25% of them (for example, a child may have trouble falling asleep, have trouble stopping thinking about the trauma they experienced, or feel unsafe everywhere they go); emotional symptoms, which affected 22% of them (for example, a child may feel alone, experience nightmares, become easily tense and nervous, feel depressed and fearful, or wet the bed); and physical symptoms, which affected 1% of them all. Currently, The United Nations says that the major mental health problems are usually found in conflict zones. According to Gaza's health ministry, more than 45,000 Palestinians have been killed since October 7, 2023. Violence and killing create trauma in these populations and affect their mental health a lot. The ongoing conflict and destruction of homes, hospitals, and basic services make the situation worse for civilians' mental well-being. Living under constant fear and seeing death affects people's psychological state badly. These conditions lead to high rates of PTSD and depression (United Nations, 2024). Veronese, Pepe, Massaiu, De Mol, & Robbins (2017) studied posttraumatic growth (PTG) Path analysis for the mediating effect of PTG on subjective well-being( SWB): Two Samples from Palestinian professional assistants in the West Bank and Gaza Strip, A structural equation modeling (SEM) was performed to examine the potential inverse and direct effects of cumulative traumas on subjective well-being, as coded from severity levels that were inversely associated with posttraumatic growth (PTG), itself positively and directly inter-related to both trauma exposure extent by an Impact event Scale-13 questionnaire used in our study method approach. This study also added that posttraumatic growth could lessen and buffer, by about 10%, the overall negative impact of trauma on a person's subjective well-being. PTG seems to provide aid workers with a means of managing the consequences of trauma. The clinical implications and recommendations for training and supervision are discussed. Since the occupation of the Palestinian Territories in 1967, the political turmoil between Palestinians and Israelis has wrought immense suffering. More than one in five Palestinians have faced incarceration during this time, with an estimated quarter experiencing a parent's imprisonment. While a father's confinement likely damages his child's psychological well-being, the full psychosocial toll on young ones, those under eleven years of age, 15 remains obscure - particularly relating to such drawn-out conflicts. The struggles have continued unabated for decades, imprisoning not just bodies but also communities and generations in widespread anguish and unresolved grievances. Furthermore, Shehadeh, Loots, Vanderfaeillie, & Derluyn (2015) sought to gain further insight into any possible mental effects of parental incarceration on young children and in what ways witnessing the arrest process may have influenced that. To achieve this objective, seventy-nine children (ages 3–10 years old) were recruited at random from the list of Palestinian men who were imprisoned and had children living in the West Bank. Separately, ninety-nine children with no family members in prison were randomly selected through schools and health facilities to serve as a reference group. Two cross- culturally validated questionnaires were used by mothers to assess the psychological well- being of their children: the UCLA-PTSD-Index and the Strength and Difficulties Questionnaire (SDQ). Some of the shorter sentences included more complex ideas, while others were slightly longer to vary the structure. The findings revealed elevated degrees of PTSD and more widespread emotional difficulties relating to a father's apprehension, and the numbers amplified substantially when the kids witnessed the arrests of their parents. Those youngsters living in rural areas demonstrated a greater probability of posttraumatic stress ratings compared to their peers situated in urban areas or refugee camps. Younger children tended to obtain higher scores on behavioural and emotional functioning measurements. Not many dissimilarities emerged when considering gender. Nevertheless, one young boy's experience stood out prominently from the rest: upon seeing the local soldiers take away his father, his usual talkative and curious demeanour transformed--now reticent, he seldom smiled and would awake screaming from nightmares. The trauma had evidently taken a severe toll on his mental well-being (El- Khodary, Samara, & Askew, 2020). Sarhan, Jarrar, Atout, & Masri (2024) measured the prevalence of post-traumatic stress disorder (PTSD), depression, anxiety, and stress among Palestinian citizens whose homes were demolished during the Israeli wars. Therefore, to measure the levels of PTSD, depression, anxiety, and stress, the Event Impact Scale-Revised (IES-R) and the Depression and Anxiety Stress Scale (DASS) were used. Two-component samples were taken, with Palestinians whose homes were demolished and others whose homes were not demolished. However, the first group recorded rates of stress, depression, and anxiety of 16 32.71, with averages of 32.61 and 32.08, respectively. However, the results of the study for Palestinians whose homes were not demolished were stress 18.46, depression 15.87, and anxiety 13.06. Three hundred and thirty-nine medical students participated. Most had been displaced multiple times, and the vast majority had lost a relative, colleague, or friend. The majority had also lost their homes and income. All participants with PTSD had at least one psychiatric disorder. Living in a shelter and having moderate or higher stress symptoms were significantly associated with depression. Being female, losing a friend, having moderate or higher stress symptoms, and having PTSD meant you had moderate or higher anxiety. Having moderate or higher depression symptoms, moderate or higher anxiety symptoms, and PTSD meant you had moderate or higher stress symptoms. Finally, having moderate or higher anxiety and stress symptoms meant you had PTSD. The study revealed very high rates of psychiatric disorders in the research sample, which was represented by a myriad of risk factors associated with high rates of comorbidities such as depression and other psychiatric illnesses (Aldabbour, et al., 2024). The studies show post-traumatic stress tends to plague many who endure wartime horrors, and the pathways producing poor mental health in civilian victims remain murky. One process deserving deeper inspection links sensitivity in relationships with developing psychopathology following traumatic experiences of conflict. Some data suggests an increased fragility within interactions may help clarify how terror witnessed transforms into later troubles like depression or anxiety. For survivors remote from battle but near its aftermath, peeling back layers on this proposed mechanism could start unraveling why trauma often torments long after the guns fall silent (Aldabbour, et al., 2024). A study by Alzaghoul, McKinlay, & Archer (2022) reviewed the consequences of war-related traumatic reactions among youth in the Gaza Strip. The selected studies used different tools and measurement tools to assess mental health outcomes, including post-traumatic stress disorder (PTSD), anxiety, depression, and resilience. The results showed that war- related traumatic experiences were common among children, such that psychological stress leads to increased mental health problems. Exposure to violence, destruction, and loss of family is a significant cause of the prevalence of PTSD. Mental health, especially PTSD, depression, and anxiety, in children and youth in the Gaza Strip is a concern for society and public health due to ongoing wars and conflicts. In a similar vein, Haj-Yahia, 17 Greenbaum, & Lahoud-Shoufany (2021) explored the association between adolescents’ attachment to exposure to EPV and subsequent PTSD symptoms. (PTSS). It explored the relationships between EPV, PTSS, and self-esteem to assess whether self-esteem had a protective effect against the influence of EPV on PTSS. Administered a self-evaluation questionnaire to two thousand nine hundred thirty-four Palestinian male and female adolescents from the West Bank region controlled by the Palestinian Authority and parts of East Jerusalem. By extensively analyzing various reports primarily via multiple regression analysis, we discovered that the higher quantity of political brutality Palestinian teenagers witnessed over the previous year as well as in prior years, the greater their symptoms of post-traumatic stress, along with its three manifestations— circumventing distressing thoughts, recurring memories, and hypervigilance. Exposure to political violence additionally influenced post-traumatic stress symptoms even when accounting for sociodemographic factors and self-worth. Girls from the West Bank recounted higher levels of post-traumatic stress symptoms when compared to their male counterparts and inhabitants of East Jerusalem. Evidence supports the enduring nature of self-esteem over time: greater exposure to violence was connected to reduced self-worth, and children with low self-esteem at this later evaluation tended to continue experiencing heightened post-traumatic stress rather than those possessing higher amounts of the same trait. Consequently, correlations between participants' exposure to violence and some of the post-traumatic stress symptoms were found to be slightly reliant on their degree of self-esteem; hence, demonstrating self- esteem wields both a moderating and mediating impact between the level of exposure to violence and the post-traumatic stress symptoms. This exploration remains limited, and the outcomes prompt further investigation to scrutinize the associations. Fathers' detention during long-term armed conflicts significantly affects adolescent mental health. It also draws attention to the severe implications for the support and care of those teenagers and their families, along with an appeal for an end to hostilities as soon as possible. The research analyzed the psychological well-being of Palestinian youth residing in difficult conditions throughout the Al-Aqsa Intifada. The study, conducted by Qouta & El-Sarraj (2004), surveyed nine hundred forty-four children between the ages of ten and nineteen regarding their experience with post-traumatic stress disorder and other forms of mental anguish. Those eliminated from the sample featured a history of prior 18 psychological issues. Some children described feeling afraid much of the time and having trouble sleeping due to scary dreams about their circumstances. In contrast, others shared that they tried to avoid thinking about the upsetting realities by keeping busy with activities, though the thoughts still intruded upon their minds. The findings highlighted the need for additional support services to foster healing and resilience among this vulnerable population enduring prolonged strife. Instruments such as the trauma scale, PTSD scale, the Child Posttraumatic Stress Index, and the Children's PTSD symptoms assessment (which correctly identified symptoms in 95% of cases), as well as the CPTS-RI and open-ended questions, were utilized to evaluate the children's experiences. It was found that over one-third 32.7% of the children exhibited acute PTSD symptoms requiring psychological intervention, and nearly half 49.2% showed moderate symptoms. Additional findings revealed that the most regularly encountered types of trauma among the children included witnessing mourning ceremonies (observed by 94.6%), violence involving firearms 83.2%, seeing injured or deceased outsiders (not relatives; 66.9%, and observing harm or death of family members (experienced by 61.6%). Varying levels of distress were reported depending on factors like gender, family loss, and injury witnessed. Accordingly, Thabet, Tawahina, El Sarraj, & Vostanis (2008) delved into how caregivers cope with persistent mental anguish due to warfare-transmitted trauma symptoms like post-traumatic stress disorder and anxiety in their children. Participants encompassed a hundred families and two hundred parents living in bombarded parts of the Gaza Strip, together with their nine- to eighteen offspring (N = 197). Both parents and children filled out assessments measuring all traumatic experiences endured, signs of post-traumatic stress disorder, and anxiety levels. The tools implemented included the Gaza Traumatic Checklist, the Children's Revised Impact of Events Scale, the PTSD Checklist for Parents, and the Taylor Manifest Anxiety Scale. The researcher sought to shed light on how dire circumstances influenced the psyche of both parents and their kids. Both parents and children recounted distressing ordeals endured and exhibited elevated scores beyond the criteria on gauges of post-traumatic stress and anxiety. For the youths, the degree of subjected trauma significantly correlated to global and subsection marks of anxiety and post-traumatic stress. However, the parents' exposure to trauma is 19 significantly tied only to intrusive symptoms of post-traumatic stress. Also, the emotional reactions of mothers and fathers to the events conspicuously correlated to the children's signs of post-traumatic stress and anxiety. Often, the psychological impacts of war trauma permeate families as their sentiments intertwine. Universal and targeted initiatives ought to embrace families. For the former, non-governmental bodies could deliver certain aid. Similarly, (Shehadi, 2018) explored the mental health of Israeli and Palestinian children as influenced by the relentless aggression. In a collaborative project, parallel instruments were developed or adapted to assess these and other variables in different societies with varying levels of conflict exposure: the relationship between trauma exposure and severity of posttraumatic symptoms (PTS); interrelationships among PTS, functional impairment, somatic complaints, and coping. A total of one thousand sixteen Israeli and one thousand two hundred thirty-five Palestinian teenagers took part. Exposure was assessed with a self-report questionnaire. PTS was considerably impacted by exposure to violence throughout the conflict, with girls experiencing higher levels than boys in both societies. The UCLA PTSD Reaction Index determined that Post Traumatic Stress levels rose alongside greater conflict-related violence. Somatic symptoms and functionality impairment showed similar increases when measured using the diagnostic interview schedule for children. Coping mechanisms varied widely when assessed through the Brief Cope inventory. While Israeli youth demonstrated a 6.8% rate of fulfilling PTSD diagnostic criteria, Palestinian young people exhibited a considerably higher 37.2%. Overall, the research highlighted how prolonged strife disproportionately harms youth mental health and stresses traditional coping responses. While adolescents in both regions reported notable hardships regarding academics, Palestinian youth struggled more severely. Students enduring post-traumatic stress displayed elevated physical ailments and troubled functionality, especially at school. Both societies' children suffer tremendously underneath constant conflict. Innovative clinical programs tailored for educational settings are desperately needed to remedy anguished psyches and fulfil pressing needs. Policymakers must prioritize youth welfare and pursue avenues to ending this prolonged strife to spare future generations from preventable suffering. 20 Khamis (2008) thoroughly investigated if Palestinian young adults who sustained injuries during the uprising demonstrated signs of post-traumatic stress disorder (PTSD) mental health issues or anxiety and despair. It was hypothesized that these psychological aftereffects could be anticipated by a combination of pre-trauma elements (like age and place), trauma-precise elements (such as recent trauma and type, deliberate versus accidental trauma), and post-trauma elements (such as social aid, coping strategies, and faith in fate). Similarly, the researcher considered whether gender or recency of the trauma experienced influenced the likelihood of developing psychiatric sequelae. The study provides insight into the long-term psychological impacts on children exposed to violence during times of political unrest. The participants included 179 youth who suffered lifelong bodily injuries during the violent Al-Aqsa uprising, leaving them physically disabled. Their ages ranged from only 12 to not yet 19 years old, averaging 16 and a half years with close to a year and a half between them. At their homes, the injured individuals answered questionnaires in an interview format. Shockingly, approximately three-quarters of those harmed developed PTSD, yet the disorder follows an unpredictable path with an increasing tendency towards constant troublesome signs and the mingling of other psychological issues like anxiety and depression. Solely where they lived, a bleak outlook and poor coping strategies significantly predicted who would experience PTSD, anxiety, and depression according to the developed models. Wounds sustained during warfare often leave teenage victims scarred inside as well as out. Psychological wounds can linger far longer than physical injuries, as shown by studies of youth impacted by violence in the intifada uprisings. Reactions like depression, anxiety, and post-traumatic stress were found to relate strongly to negative thought patterns like helplessness and an inability to alter fate. Cognitive behavioral therapy proved promising for mitigating such aftereffects by challenging unhelpful beliefs. In treatment, counselors must directly confront and attempt to reframe thoughts of a lack of control over circumstances or one's emotions. Narratives of trauma and recovery should explore resilience while varying in complexity to engage clients on diverse levels. Studies have found that many Palestinians, especially those in the Gaza Strip, suffer from symptoms of PTSD. A study by El-Noor & Abu-El-Noor )2020) showed that 92.6% of 21 participants had scores above the cutoff point of 35, which means that they had severe PTSD symptoms. The study conducted by Gammoh, et al. (2024) aimed to investigate the impact of depression, PTSD, and insomnia in a group of Palestinian refugees residing in camps in Jordan during the outbreak of the war on Gaza on October 7. The Patient Health Questionnaire (PHQ-9) scale was used to assess self-reported PTSD symptoms using the Brief PTSD Scale, and the severity of insomnia was assessed using the Insomnia Severity Index - Arabic Scale (ISI-A). The results showed that major depression was reported at 69%. In addition, 49.2% also suffered from severe symptoms of PTSD, and this percentage indicates that 60.5% suffer from severe symptoms of insomnia. Studies have indicated that Palestinian refugees in Jordan have affected mental health through high rates of depression, PTSD, and insomnia. It has been noted that the conflict in Gaza is associated with mental health challenges, especially among Palestinian refugees residing in Jordan. Post-traumatic stress disorder (PTSD) and major depression are the most common mental health problems resulting from war and conflict, especially in the Middle East, Africa, and East Asia, such as Palestine, Iraq, Syria, Eritrea, and Myanmar. Evidence and studies indicate that individuals exposed to wars and conflicts develop mental health problems. Many studies have confirmed that PTSD leads to serious mental health problems, including increased depression, stress, and anxiety (Aldabbour, et al., 2024; Amro, 2024; Melese, et al., 2024; Mughasieeb, 2022; Manzanero, et al., 2017). 1.7 Conclusion The effects of the conflict have been evident in this chapter. The literature review showed studies on resilience that were done in the context of Palestinian culture. Following the first and second chapters, which discussed trauma, the next chapter will discuss the methodology, including pattern selection, how the data were acquired, and how they were analyzed. 22 Chapter Two Methodology 2.1 Research Design AbuHamda, Ismail, & Bsharat (2021, p.71) stated, “Qualitative and quantitative approach methods are the engine behind evidence-based outcomes.” thus, this study research used a qualitative design with a phenomenology approach to study psychological trauma in Palestine. Thirty-two participants aged 18-40 who faced war trauma were chosen through purposive sampling. The study collected data through Arabic interviews that were recorded, written, and coded later. The interviews asked participants about their trauma experiences and how they dealt with them. The study used Braun & Clarke's (2006) method to find common themes in participants' words. The researcher used this approach because it helps understand how Palestinians experience trauma from war and occupation. The researcher kept all information private by using unreal names and storing data securely. This design helped get deep information about trauma experiences directly from Palestinians who lived through it. 2.2 Sampling strategy Purposive sampling was utilized in this investigation as Welman & Kruger (1999) discussed how, during phenomenological exploration, sensation essentially determines the technique and type of individuals involved. Purposive sampling is the most critical non-probability sampling strategy for pinpointing essential individuals. The sample of this study was 32 participants who were chosen purposefully. The researcher handpicked the examples dependent on individuals who are dealing with traumatic functions because of occupations. In addition, they had been purposefully chosen to respond to the investigation goals. The investigation people comprise all grownup folks between the ages of 18- 40 coming from all over Palestine, who struggle with war traumatic activities. The discussions with the participants were audio-recorded with the consent of the individuals involved. Individuals' inclusion/exclusion criteria were as follows: - Individuals have to have straight knowledge of traumatic activities due to the war and be prepared to discuss their experiences. - They must be adults between the ages of 18 and 40 years old. - Be in stable mental health without any major psychiatric conditions 23 2.3 Ethical, Access, and Political Consideration Every stage of the examination meticulously considers social and ethical factors. No volunteer underwent any physical or psychological harm as a result of this research, it is essential to note. Individuals with an inherent right to autonomy, privacy, and confidentiality were consulted at each study phase. Participants were not pressured or coerced into signing up for the experiment; they were free to independently determine whether or not they wished to continue their involvement. Pseudonyms have been employed to protect the privacy of identifying information obtained from interviews. Other materials were secured in a locked cabinet, while audio recordings of discussions were stored on password-protected systems only accessible by researchers. Through rigorous protocols, our team ensured that the sensitive data gathered remained inaccessible to all but these investigators. 2.3.1 Ethical approval On August 28th 2023, Najah National University's ethics committee (Mas. August. 2023/43) granted formal approval for the research project after a thorough review. Participants were given detailed written information explaining the study's aims, voluntary nature, and assurances of anonymity. Consent forms were distributed and later returned signed to the sole researcher. Only the primary researcher and supervising faculty had access to the centralized file of all collected data. Recorded interviews from participants were kept strictly private. As privacy and confidentiality of any personal disclosures were pledged, no names or identifying characteristics were included to maintain the complete anonymity of all contributors. As stated earlier, consent was secured from the Palestinian Ministry of Health to gather data from participants in Nablus. A letter requesting a written agreement will be issued to each person involved. Acquire the Institutional Review Board's Report of Action from An-Najah University after examining ethical procedures like privacy, voluntary participation, and what is expected of those contributing. Before speaking with any individuals, an information page was provided to clarify the intention behind the research project while emphasizing the importance of confidentiality and that participation was by choice. 24 2.3.2 Inviting participants to participate Mental health centres were sought, and authorization was obtained to reach the patients suffering from psychological trauma as a result of the occupation; after the cases were approved, they were called for an interview. It is worth noting that they are not diagnosed with PTSD but they experienced traumatic events. Participants were also identified by asking acquaintances about persons who had been through traumatic events, and after their agreement was obtained, they were contacted. Participants were fully informed of the reasons for their participation, and there were no identified fees, risks, or advantages. Participants were informed that there were no direct benefits and that what they mentioned could only be used for research purposes. Pseudonyms were used for all participants' names and addresses. The pseudonyms occur once the statistics have been collected before being analyzed. If anyone decides to withdraw, individuals are notified before the announcement of the conclusions of inquiries; the statistics will then be abandoned and not used. When a player withdraws after the thesis has been completed or when statistics have been used in magazine articles and presentations, the statistics can no longer be used in similar publications. For participant selection, the researcher faced many challenges. Initially, the goal was to sample individuals diagnosed with PTSD, so the researcher requested formal university permission to access psychological institutions and centers. Upon receiving permission, the researcher approached all psychological institutions in Nablus. Some institutions refused to allow researcher interviews with patients due to institutional policies, while others informed the researcher that few PTSD-diagnosed patients visit monthly for medication. They asked the researcher to wait at the institution for patient arrivals. This made the process difficult, complex, and time-consuming. The researcher then approached prisoner care institutions and families of martyrs to interview individuals with family members who were prisoners or martyrs. After some individuals agreed, their phone numbers were obtained, but WhatsApp blocked the researcher's account. Subsequently, the researcher attempted to obtain participants through acquaintances and friends, meeting six females in their homes in Tulkarm camp during the invasions. The main supervisor of the researcher assisted in this process by providing contact information for a worker from Gaza who had experienced traumatic events while working in Israel and relocated to Nablus following October events. This worker helped the researcher to 25 interview several similar Gazan workers in Nablus who experienced trauma, particularly during the October events. The researcher requested to conduct interviews at the university but was denied permission. The university asked the researcher to conduct the interviews at the participants' residences in Nablus. Finally, the researcher heard many painful and sad stories that caused her psychological state to deteriorate from the horrific events the researcher heard. 2.4 Data Collection Tools Data were collected through two primary tools. The first was interviews, which included conducting specialized interviews with some individuals who suffered from the disorder. The second method was a purposive sample to achieve the objective of the study. The interviews were used to gather data for various reasons, including that they provide ways to rationalize undefined experiences. Compared to purposive sample, interviews have a higher response rate; they offer greater understanding, and this kind of verbal exchange with depth is more conducive than any other form or media with which to bring out the elixir of ideational delight (Schultze & Avital, 2011). In-depth semi-structured interviews were utilized as the primary source of data collection to understand the key reasons leading to psychological trauma in Palestine. Identifying the main causes of psychological trauma differed between males and females in Palestine. Females often experienced trauma due to threats of assault from occupying forces, whereas males faced beatings and arrests. The typical reactions of traumatized people under occupation varied greatly. Palestinian culture and context significantly contributed to trauma. The strong value placed on homeland and religious sites meant losses were cut deeply. Meanwhile, the mental health specialist plays a pivotal role through various interventions. However, resources for treatment are limited amid the prolonged occupation. The reasons for the rise in psychological trauma are multi-factorial. Prolonged military presence, settler violence, and loss of land and livelihoods all undermine a sense of safety and dignity. To prevent further trauma, international pressure is needed to end the occupation. Locally, community support networks and access to care must be strengthened for Palestinians to heal from generations of oppression. 26 The researcher spent weeks crafting a series of open-ended queries to explore the harrowing toll of psychological suffering endured by the Palestinian people. Their interview protocol, informed solely by an exhaustive survey of academic writings, aimed to elucidate shared threads of hurt while illuminating singular shades of individual anguish. A candid dialogue, they knew, could shed light on how different experiences of the same violent events impact human cognition, emotions, and behaviours in disparate ways. At the same time, a loosely structured exchange might reveal commonalities in coping and perspectives that previous distant readings had failed to detect (Freitas, Oliveira, Jenkins, & Popjoy, 1998). Data was gleaned through in-depth, semi-structured interviews exploring various aspects of psychological trauma from the perspective of those afflicted in Palestine. Therefore, the researcher crafted questions to thoroughly capture the essence of participants' experiences. The interview questions aimed to elucidate the primary causes of trauma, gender differences in impact, expected effects on daily living and coping strategies across cultural contexts. Additionally, they sought to understand the roles of mental health professionals and the means of preventing future trauma. Interviews took place privately in participants' homes, lasting approximately forty-five minutes each, and recorded with consent. It is worth noting that these recordings are available upon request from the researcher. Since the sample of the study includes individuals who experienced trauma, it is a bit sentnestive to publish such data. Thus, the researcher kept the recordings available in a safe database and made them available to other researchers upon formal request. The literature guided question development. 2.4.1 Interview process The study's beginning documentation guided engaging discussions to address the research's fundamental inquiries. The interview handbook was painstakingly crafted before the discussions and focused on unpacking the psychological anguish of specific vocations. The researcher built the questions of the interviews based on the literature review. These questions underwent scrutinizing review, rewriting, and reorganizing to be better comprehended by the individuals. Questions drew inspiration from the researcher's findings when scrutinizing the psychological suffering caused by occupation in Palestine. These manual interviews were strategically scheduled following profound dialogues with the supervisor, Dr. Mohamed Marie. Given that the interviews were in Arabic, the 27 following pre-planned questions or activities were translated into that language (McCracken, 1988). Validity and Reliability of Research Instruments The researcher used many methods to test the validity and reliability of the instruments. Three clinical psychologists and two research methodologists reviewed the interview guide and the sample for validity. Their feedback was taken into consideration. The researcher then modified the question wording and structure to make sure that they met the research objectives. The Arabic versions of the instruments were translated. Two independent experts tested the translation quality (forward and backward translations). After that, one linguist made sure it was appropriate that they test what they were designed for the sample. Regarding the themes, the study relied on psychological trauma theory which is based on the work of several scholars such as Breuer, Freud, and Bessel van der Kolk. In fact, the researcher coded and categorized participants' statements and created headings based on participants' responses. In the discussion, examiners indicated that redundant or unclear variables could be removed, such as ("mixed feelings"), and to avoid using psychological terms that suggest the researcher is diagnosing participants, like the term (anxiety) and replace it with a more neutral term meaning tension. To increase the trustworthiness, all interviews were recorded using audio recorders. A local Palestinian completed transcription within the colloquial language (neighbourhood Palestinian dialect), and he or she compared the correctness and dependability of the two recorders. The transcription is then completed for the primary recorder as opposed to the secondary recorder. Then, the researcher examined and reviewed every single sentence and the transcription within the first recorder, line by line. Then, to ensure accuracy and reliability, the researcher checked each unmarried phrase with the second recorder. Recording and transcribing interviews provides several advantages, including the ability to examine people's responses through repeated listening. It also reduces the researcher's hurdles, such as proximity to a specific meaning of what an interviewee claimed following the interview. It helps with the evaluation procedure by revisiting the researcher's or other researchers' audio data. Transcribing and reviewing transcription becomes a time-consuming process (Bryman, 2016). 28 In qualitative research, credibility refers to the authenticity of research conclusions. The researcher meticulously maintained thorough documentation, transcribing all interviews word for word to allow readers to grasp contributors' lived experiences in their own words. Through continual self-examination, the researcher employed reflexivity to detect and address her own prejudices, composing field notes that scrutinized how biases may yet infiltrate and influence her work at each phase of the project. By such means, one can work to ensure the integrity of qualitative findings remains uncompromised by the preferences or preconceptions of the researcher herself (Ary, Jacobs, Irvine, & Walker, 2018). 2.5 Data Analysis Braun & Clarke (2006) skillfully theorized multiple perspectives regarding the theme analysis method in their seminal 2006 work. For an array of pragmatic and philosophical reasons, employing this interpretative qualitative approach enables one to harvest insight while upholding congruity. It facilitates an exacting yet nuanced portrayal of resilience assets intrinsic to a community's culture. This adaptable framework is apt for the psychosocial examination of findings. At the same time, as Braun & Clarke (2006) later observed, it serves as a potent investigatory implement when exploring topics emergent from qualitative data. The researcher concentrated on discerning prevalent living styles and participant interaction in the present study. Themes distilled from the data may centre on a pivotal notion or idea critical to fulfilling the objectives of the inquiry. As DeSantis and Ugarriza (2000) previously defined, the preceding analytic technique systematically identifies, analyzes, and reports patterns within a corpus. 2.5.1 Data Analysis Process The interviews were tape-recorded and later transcribed in full, capturing the participants' own words. Observational notes were also taken during disciplinary hearings. These interviews, notes, and collected documents were analyzed to discern patterns and themes. The goal was to categorize the information to make comparisons between various accounts. In this way, relationships might emerge, and insights could be gained. Longer passages allowed for complexity while shorter phrases-maintained flow. The classified research materials facilitated the evaluation and understanding the underlying issues (Maxwell, 2012). 29 These preliminary records and codes have been assembled to commence a foundational sub-topic aggregation. The applicable codes imbue significance regarding the research's destinations. An eclectic assortment of codes was enlisted. At the outset, consideration centred on mesmerizing interview excerpts that hinted at underlying attitudes. Subsequently, a duo of classifications interpreted the implications of those extracts to deduce the perspectives espoused by participants. Ultimately, bringing order to the collected data should enhance comprehension of the subject under examination (Maxwell, 2012). These early transcripts and numerals have been compiled to begin a fundamental subtopic accumulation. The pertinent symbols lend importance to the inquiry's destinations. An eclectic mélange of codes was listed. Initially, attention centered on fascinating dialogue excerpts that hinted at underlying attitudes. Subsequently, a pair of categories interpreted the implications of those extracts to infer the viewpoints espoused by individuals. Ultimately, bringing organization to the collected information should heighten comprehension of the topic under analysis. Furthermore, a deeper dive into some of the more intricate interview responses exposes additional nuances within participants' perspectives. Creating an in-depth subject file by selecting examples with an attractive character can contribute to the results. In addition, examining those cases and linking them to a comprehensive review of the study objectives (Bryman, 2016). The researcher used the step-by-step manual outlined by Anne-Marie, Chau, & Kai (2017) to analyze the qualitative data systematically. In the initial stage, they immersed themselves in the material by thoroughly examining each line of transcripts, notes, and files. They sought to comprehend the full scope and nuances of the collected information. Next, preliminary codes were identified by highlighting striking concepts directly linked to the study's aims. Intriguing capabilities and early extracts suggesting relevance were marked using distinct colors. These temporary labels attempted to capture nurses' resilience under stressful conditions, as depicted throughout the textual sources. Potential sub-themes emerged in the third phase by aggregating applicable codes from all sources into computerized tables organized by capacity domains. The compiled excerpts were sorted and grouped to start forming a cohesive narrative. Step four entailed validating the 30 accumulated codes and evaluating if they properly fit within the provisional sub-themes. Some codes were combined, while others required reclassification. The sub-themes continued refinement to ensure the extracts logically contributed to the overarching story. The fifth stage refined the names of the sub-themes, making the entire story conveyed by the records more sensible and coherent. Subsequently, the sub-themes were translated from Arabic to English to widen their accessibility. The seventh phase consisted of a final review examining the findings. Lastly, the sources were reexamined to identify any remaining materials relevant to the core topics uncovered throughout the process. 2.6 Conclusion This chapter has focused on the study's methodology. It began with a reason for the research, followed by the presentation of a stylish purpose and specific research objectives. It also included a discussion on the use of qualitative designs and data generation strategies. The bankruptcy gave grounds for the investigation's use of interviews, statements, and amassing information. The special power of interview approaches is addressed, and the use of qualitative tools to examine resilience is presented. The bankruptcy has also offered a method of moral approval and access to participants in order to generate knowledge. There have also been discussions about sampling, information control, and analysis. The session concluded with sections on reflexivity and how to sell qualitative study quality, validity, and reliability. 31 Chapter Three Results 3.1 Introduction This chapter discusses the symptoms of psychological trauma, its causes, and coping strategies among Palestinians due to the occupation. The data consists of 33 interviews conducted with war victims in Palestine, particularly after the October 7 war in Gaza and Tulkarm . The results are presented as themes/sub-themes in Table 1 (see Appendix A) related to participants' responses to the interview questions. This chapter contains excerpts from participant interviews to support the clarity and credibility of the topics. In the following sections, the researcher shows how the study sample experiences and responds to difficult events in their lives. The researcher divided them into themes to help the reader understand these experiences better. These themes show in detail what kinds of challenging situations people face, such as their direct experiences and what happened to their loved ones. The themes also describe how losing access to basic needs affected their life habits. Additionally, these themes show how the study sample reacted when facing these difficult situations. The main thing noted among them is that they responded in different ways through their feelings, physical symptoms in their bodies, and changes in how they think about things. Similarly, these themes show how lacking basic necessities, like food, shelter, and ways to communicate with family, made these challenging experiences even harder for them to handle. The themes in this study were formulated through a systematic qualitative analysis process using Braun & Clarke (2006) thematic analysis method. First, the researcher began with a review of all interview transcripts. Then, the researcher carefully read the data two times to be familiarized with the participants' experiences and responses. After that, the researcher developed the main themes in the participants' responses during the initial coding phase. Hence, the researcher grouped these initial codes based on their similarities. For example, some codes were merged together when the study sample described similar experiences of direct exposure to traumatic events. Then, the researcher reviewed these codes and turned them into themes. For quality purposes, the researcher examined how different codes related to each other and could create sub-themes from them. This process led to the creation of the main and sub-themes. To ensure the validity 32 of these themes, the researcher regularly consulted their supervisor and other researchers in the field to make sure that the themes accurately represented participants' experiences. 3.2 First Theme: Traumatic Events Results related to the first research question: "What is the common cause of psychological trauma in Palestine?" Three main themes that formed symptoms of post-traumatic stress among Palestinians due to the occupation will be presented. These themes consist of direct exposure to harm, relatives being harmed, and lack of basic resources for life. Each one of these themes includes several sub-themes as follows: 3.2.1 Direct Exposure to Harm One of the themes causing psychological trauma resulting from my data relates to the context of direct exposure to harm and includes being present during the bombing, being under rubble, being present during home invasions, exposure to violence, arrest, and tangible dealing with the injured and martyrs such as transporting or treating them. The following sections present a detailed analysis of each theme separately . 1. Direct Exposure to Harm: Sub-theme - Presence During Bombing Among the 33 participants, five experienced psychological traumata due to being in areas affected by bombing (see Chart 1). Below are excerpts from the interviews conducted with each of these individuals. Participant 11 indicated that he was present in Gaza under bombing while praying in the mosque. He felt the ground shake beneath him as a result of the bombing, so he hurried to his house after the prayer to check on his family, and a barrel bomb hit their house, causing a fire. The participant carried his daughters and hid them in a safe place. Here is a quote from his statements during the interview: ".. But I was praying the evening prayer in the mosque, and I was 200 meters away from them when the bombing started while we were praying, the ground shook... I carried the two girls and I was about to carry them when a barrel bomb hit us, you can say it set everything on fire, the fire entered our place, I carried them and kept running with them down the stairs, this was the only time I feared for them while in Gaza ". 33 Participant 19 also indicated that she was present during the bombing in her home for a whole night. Here is a quote from her statements during the interview : "The Israeli solders were hitting at the door of the house... yes, there was bombing... I mean how the young men... were resisting at the door of the house... and the bulldozers started entering at the door of the house.”. Participant 21 indicated that she was in the house during the bombing, where she was lifted and fell to the ground as a result of the bombing. Here is a quote from her statement during the interview : "Anyway, when they hit us at the door of the house, I couldn’t tell what happened exactly to me.. and how all of my body was lifted and fell to the ground..” Participant 24 also indicated his presence during the bombing in the Fakhura massacre and his involvement in helping paramedics collect body parts. Participant 30 indicated that he was present during the bombing at different periods of his life. In 2008, he was in the mosque and hid in one of its corners during the bombing. In 2021, he was present during the bombing while at work and fled with the bombing above him and part of his house was also demolished. According to DSM-5 criteria, exposure to actual death or threat of death or serious injury through direct exposure to the traumatic event is one of the criteria applied to diagnose post-traumatic stress disorder. 2. Direct Exposure to Harm: Sub-theme - Being Under Rubble Among the 33 participants, two suffered psychological trauma from being trapped under rubble. Below are excerpts from the interviews with each of these individuals. Participant 13 indicated that his house was bombed in 2020 while he was inside, which caused him to faint and suffer physical damage. Here is an excerpt from the interview in which he talks about this difficult experience : Yasmin: Was there bombing near you while you were in Gaza ? 13: While I was in Gaza, in the 2020 war, we were buried.. under the rubble... they got us out from beneath the rubble and the roofing sheets. 34 Participant 21, whose house was bombed, explains how she removed glass shards from her daughter's face and fled, saying: "I came to take her and go... they bombed again another strike. The glass fell on my girl's cheek... while she was sleeping... I was carrying my daughter and the bag, intending to go to my uncle's house upstairs... suddenly, my cousin came in... the drone hit him and my husband, but I did not know that my husband had been hit...”. 3. Direct Exposure to Harm: Sub-theme - Presence During Home Invasion Participant 18, an 18-year-old, indicated that her house was invaded by the army while she and her elderly mother were present without a man in the house, which affected her psyche and daily life significantly. The girl describes the event by saying : " When they entered, the aggressive way they entered had scared us the adults.. imagine how it would do to the young... I mean you wouldn't expect how really really scary it was, I mean my mother went to open the door, they did not wait for my mother to open the door. As soon as they knock, if you do not open the door right away they break it". 4. Direct Exposure to Harm: Sub-theme - Exposure to Violence Participant 15 indicated that he was subjected to violence by security personnel while he was in Nablus because of a joke he said, as they mistakenly thought he was smuggling hashish, which caused him deep psychological harm as he believed that the real enemy is not blamed because he is an enemy, but he couldn't understand why his brothers were against him too... He describes his exposure to violence by saying : "They dragged me.. handcuffed me, I can handle one or two of them but not 7.. and they took me inside like this, tied me to a chair... and they kept beating me... the five beat me”. 5. Direct Exposure to Harm: Sub-theme – Arrest Participant 25 indicated that he was arrested for a whole night on charges of being in Israel without official permission, which made him feel afraid, and this is a quote from his description of what happened : " I was scared, scared when I first arrived and I was handcuffed .. and I understand that those who are caught are deported to Gaza and I do not want to go to Gaza, I cannot imagine living the life they are living honestly”. 35 6. Direct Exposure to Harm: Sub-theme - Tangible Dealing with the Injured and Martyrs Four out of 33 participants, whether through their jobs as rescuers or as volunteers, witnessed and dealt with painful scenes of the injured/martyrs during their work and attempted to transport the martyrs or save whoever could be saved from the injured, and there is no doubt that these scenes and dealing with them have a psychological impact on those who face such events. The following are excerpts from the interviews with the participants: Participant 12, who worked as a paramedic in Gaza in previous wars, indicated that in one of his attempts to rescue an injured person in Gaza, he tried to get him out of the burning car, and suddenly, the severed foot was in his hands, which shocked him. He describes to me one of the events that left an impact on him. “Once in the 2014 war.. they bombed someone in front of the ministry.. I went out with my colleague to rescue him, we carried the fire extinguishers, put out the car, opened the door.. his leg came out in my hands, I put it in the ambulance.! .. but after that maybe I stayed for about 3 days not comprehending what happened ". Participant 20, who also worked as a paramedic, indicated that she was treating her nephew whose foot was amputated, and she spends most of her time working. Here is an excerpt from the interview on the subject: 20: I was treating injuries Yasmin: You're a paramedic, so you see a lot ! 20 : Yes, and my nephew's hand was cut off in the house upstairs and I was with him . Participant 23, who worked as a paramedic at the beginning of her career and at the beginning of her work as a paramedic, the first injury she received was her brother's injury, according to her statement. Participant 24, a volunteer who was helping paramedics in Gaza, was collecting pieces of martyrs' bodies and putting them in bags. 36 3.2.2 Relatives Being Harmed One of the themes causing psychological trauma resulting from my data relates to the context of relatives being harmed and includes losing a relative, injuring a relative, arresting a relative, danger in the family area, and suffering a friend. The following sections present a detailed analysis of each theme separately. 1. Relatives Being Harmed: Sub-Theme - Losing a Relative Among the 33 participants, 27 individuals suffered the loss of at least one loved one during the recent events in Gaza, which caused them psychological trauma. Here are some excerpts from the interviews conducted with them regarding their loss . Participant 1 indicated that he lost his father, saying: "Before my house was demolished, my father was martyred, I got the news of my father’s death". Participant 3, who was forced to live a life that was not of his choice, as he married his martyred brother's wife to raise his children, said: "My brother was martyred and my father got married and his wife raised us, she is respectable. She is my wife's sister now. In 2006 my older brother was martyred, and he had a son and a daughter, so my father suggested that I marry my brother's wife to raise my brother's children ". And in the recent war, he also received news of his younger brother's martyrdom. He describes receiving the news as follows: "On October 7, it was Saturday, I was off work, the guys came to show me the news, they tell me look look.. I saw jeeps entering Gaza.. so in the afternoon they brought me news that my younger brother was martyred". Participant 4 indicated that he lost many relatives in a tragic event in which 57 martyrs died, and during my interview with him, he also received news of his friend's martyrdom. 2. Relatives Being Harmed: Sub-Theme - Injuring a Relative Among 33 participants, 12 had at least