Training Women Graduates as Human Relations Counsellors and Researchers in Gaza, Palestine: “Beyond Brokenness”—A Planned Research Framework

Background: The people of Gaza, Palestine have suffered profoundly since conflict with Israel began in 2000, with the resulting warfare and blockades. Following a series of external bombardments between 2000 and 2014, much of Gaza’s infrastructure has been destroyed, without hope of rebuilding. Many schools, hospitals and colleges have been destroyed. Public health conditions are deteriorating, and physical and mental health of women and children has been profoundly affected in negative ways. Post-traumatic stress following numerous bombardments is a major problem. Mental health of adults and children is declining, but no information is available on changes in mental health after the most recent conflict of 2014. Methods: Firstly, this paper offers an overview of psychosocial survival in Gaza, Palestine and potentials for strengthening psychological resistance to future trauma. A proposed research programme is outlined, which aims to create a cadre of ‘resilient women’. We have planned, with local cooperation, a programme for creating a cadre of strong and resilient women, who can counsel and support others in offering social and psychological supports, through a modified form of cognitive behaviour education. Measures to be used in the main study have been successfully piloted, and plans established for recruitment of 100 “resilient women” graduates, through social network analysis. Results and Conclusions: Political barriers to effective implementation of this research programme are outlined.


Introduction
The nation of Palestine is divided in two halves. The larger part of Palestine, the West Bank, is relatively prosperous; but Gaza has experienced diminished income and economic activity since repeated conflicts with Israel between 2000 and 2014, in which much of Gaza's infrastructure has been damaged or destroyed, including a halt to the building and repair of schools, hospitals and health care facilities since 2014, because of the Israeli-imposed blockade. Male unemployment post 2014 is at least 50%, and income per head low, and is likely falling. A UN Report on Gaza with data up to 2011 [1] observed that since the Israeli blockade in 2005, GDP per head had fallen to $1165. The Israeli military action in 2014 will certainly mean that income per head will fall further still. The majority of men are unable to work productively, and contract labour in Israel is no longer possible since the closing of the border. Egypt too now tightly controls the border with Gaza, and the port is no longer operating. These blockades have prevented the import of building materials for reconstruction; and clean water and electricity supplies are intermittent. Sewage disposal is a major problem, and in this respect access to unpolluted drinking water is a much greater problem than in the Occupied West Bank [2].
Research since 2001 has shown the health disadvantages for Gazan women and children in terms of perinatal morbidity and mortality, anaemia and stunting of growth prior to 2014 [3]. In the 50-day bombardment of Gaza in July and August 2014, 26 schools were destroyed, and a further 122 schools and colleges badly damaged. 421 higher education students were killed, and 1121 injured (551 with severe shrapnel wounds, crush injuries or burns). For 1270 higher education students, a family member was killed [4].
Almost certainly, poor physical and mental health in children and adultsdescribed in earlier studies [5]-has deteriorated since 2014, to an unknown degree. External researchers now have great difficulty in entering and leaving the Gaza coastal strip, because of controls imposed by Israel and Egypt. At present only aid and relief agencies (e.g. UNWRA, ANERA, MAP, Islamic Relief, Save the Children) are permitted to enter Gaza, in order to deliver education, health care and food aid.
One of the beacons of hope in Gaza is that several Universities remain independent, and are not under external political control, even though many suffered physical damage in the 2014 onslaught [4]. Our focus university, which we propose as a partner in the research programme outlined below, earns most of its funding from its (moderate) fees from students, and grants from independent bodies, including UNDP, Paltel Communications, The Qatar Charity, and international bodies such as Islamic Relief, and The Islamic Development Bank.
Founded in 2000, it has some 25,000 students in eight faculties, and produces annually around 3000 women graduates a year (from whom we plan to recruit our 100 interviewers). Situated in south west Gaza, its campus was not directly affected by bombing, shelling and rocket fire in 2008 and 2014.
Despite the high quality of the graduates, the large majority remain unem-ployed, and are unable to leave Gaza to look for work. A published study (undertaken prior to 2014) [6] has shown that accomplished women graduates of Gazan universities had been occupying key roles in the telecommunications industry. The women of Gaza are a source of strength and hope [7] [8] [9]. The research of ourselves and others has shown that Arab women are not only "strong family managers", but are also highly efficient professionals when they enter the external work force. We propose to draw on, and develop such strength in this Gazan research.
We have proposed, in a research link with the co-operating institution in Gaza, Palestine to train 100 women graduates with a background in human relations management, as qualitative and systematic data recorders, and promotors of adult strengths and coping skills, using the critical realist model of research. This critical realist model, which has been used successfully by Muslim researchers [6] [10], assumes that there is a real basis in social structure on which to ground value assumptions, and achieve social change [11].
We are keenly aware of the lack of systematic data, post-2014, on adult health, social skills and human resources in Gaza, a region which endures chronic poverty and shortage of medical facilities, lack of sources of nutrition, and opportunities for many kinds of paid employment. Studies prior to 2014 have found (after the 2008 conflict) elevated rates of malnutrition, child mortality and morbidity, and post-conflict psychological disorder [12]. Of particular concern to us is the literature on Post Traumatic Stress Disorder (PTSD), showing high rates of such stress disorder in children, adolescents and adults in Gaza [13]. This work was carried out before the 2014 bombardment and blockade, and it is likely that the situation in terms of personal adjustment of citizens post-2014 will have become appreciably worse.

The Planned Research
In order both to assess this hypothesis or idea (that levels of adjustment are declining in Gaza, because of the unresolved effects of multiple trauma in conditions of siege and warfare), and to obtain qualitative accounts of women's lives "living under siege", we are recruiting 100 recent female graduates in human relations management from our co-operating institution in Gaza, and under university auspices, plan to train them in the collection and recording of personal accounts of themselves and others, including the collection of data on parameters of women's healthy adjustment.
We plan further to deliver online, brief education in Cognitive Behaviour Training (CBT) to these 100 women. CBT has been shown to be highly successful in helping individuals 'outgrow' prior stressors as psychologically healthy adults who can meet and overcome fresh challenges, and help others to do so [14] [15] [16]. The motto of CBT is "Think Good, Feel Good"-but in order that this shall not be a facile, culturally inappropriate model for a Muslim culture, we are adapting the basics of CBT so that it is appropriate to the Gazan situation [17]. First of all, the idea of "therapy" in the adaptation of CBT should not be palliative therapy, but co-counselling between women in order to achieve strength and resilience, looking to the future rather than the past [18] [19].
Critics have rightly pointed to the importation of psychopathology models developed in Western settings as potentially demeaning to a population under siege [20] [21]. Characterising a sector of Palestinian adolescents and adults as "permanently broken" in spirit, as some researchers have done [22] [23] is unhelpful, and demeans the victims of Palestine and Gaza.
Rather, we seek to identify psychological resilience in the face of multiple stressors [24] [25]. We plan to go beyond the concept of post-traumatic stress disorder which some have described in Gazan survivors, arguing instead that with the likelihood of further trauma-including events in the years to come -Gaza needs a core of "strong women", well-trained and aware of ways in which newly-traumatised individuals can be helped [26]. We name our project after the Prophet Ayoub, who was not "broken" by the tests he had to endure. With Dr.
Izzeldin Abuelaish, whose three young daughters and niece, were killed by Israeli shelling of Gaza in January 2009, we advocate non-violent solutions to the problems of Gaza. Dr Abulaish's (2012) book is titled I Shall Not Hate [27], and his work has led to the founding of the "Daughters for Life" Foundation, whose advocacy of action in Israel, Palestine and Gaza (fostering the education of both

Jewish and Muslim girls) follows the non-violent examples of the life and teach-
ing of Prophet Muhammad [28].
The research we will undertake employs, in the methodology of public health research, 'mixed methods', both qualitative and quantitative [29]. The initial, qualitative design will elicit brief, autobiographical life histories from the 100 women recruited, and we will ask them to identify stressful factors in their lives as children and adults, and how they attempt to overcome these stressors. The only quantitative measure employed at this stage is the Arabic version of the CESD (Center for Epidemiological Studies of Depression Scale), which we have used before, and which has established cross-cultural validity with this population [30]. We have adapted this scale into an 11-item "positive self-regard inventory", measuring an individual's capacity for growth, change and permanent strength. This "baseline adjustment" measure will enable us to measure positive and negative changes in coping strategies over time, in relation to unknown political and social changes.
Our declared aim is to develop "100 women" who because of their intellectual achievements and personal strengths, have succeeded in acquiring the "cognitive behavioural" skills of confronting and coping with future stressors in ways which enable them to empower other women (and indirectly, their male kindred, children and partners). We recruit these women through social networks of manifestly resilient women, using the social network methods developed in qualitative research [31] plan to train the hundred women through standardised, web-based materials, with short in-service training at the co-operating University, delivered by a professionally-trained instructor. All of the 100 women re- Many of these women will have children, and will work in the proposed research programme part-time, in a mainly volunteer capacity, but with payment for course attendance, and the transmission of collected data to the project's co-ordinators. Each specially trained female graduate will, following models of research in Palestine West Bank and Gaza [32] [33], identify through her personal acquaintance network, one woman who is 'strong', surviving stress, and one who seems to be failing to cope. The 'life stories' of these women should provide valuable qualitative data on women enduring stress in Gaza, and their modes of coping.
These data are recorded in Arabic on smart-phones. We have planned a three year, longitudinal project in which each interviewer will contact two young mothers whom they will interview and counsel approximately six times over the three year period of the field research.
The data gathering begins with a brief initial biography, first of the researcher herself according to structured guidelines learned in training, and then of each woman interviewed by the key researcher, followed by questions on personal health, according to short, standardised questions; and data on the health of her family members, including children and the elderly. For political and cultural reasons, adult males of working age are not being interviewed in this study. All interviews are in Arabic, and will be transcribed later into English, for purposes of qualitative data analysis.

Results and Conclusions
This research programme has been planned as an exploratory study, rather than one involving a rigorous, hypothesis-testing model, and aims to explore the underlying idea that the longer the blockade (border and port closings) of Gaza lasts, the more the physical and psychological health of women, children and the elderly might deteriorate. If there is further violence between Gaza and Israel, we presume that the parameters will indicate a significant worsening of the physical and mental health of those whom the women graduates will interview. Using these data, we have proposed the construction of a narrative, critical realist account of family life in a region experiencing an unknown future. We have planned through the accounts of these women, to tell their stories and those of their children-of suffering, of endurance, of hope, making them available to a wider political audience.
A pilot study of 10 women graduates has established the feasibility of the methods we propose to use, including the recording of interview and test data using mobile phones. The initial validity of the instruments and methods (Cognitive Behaviour Training, and The Strengths and Coping Questionnaire) has established the promise of these novel approaches to the research, which aims to create a cadre of well-trained human relations personnel. This research cannot be carried out at the present time, despite the promise of funding from a foundation for a three-year study. The full research programme has been put "on hold", because the principal people involved (including the present writer) have been denied relevant "work permits" by the Israeli authorities, which has complete control over who may enter and remain in Gaza, for whatever purpose. Bagley, a Muslim-Quaker pacifist [28] and a vocal critic of the main Israeli and Palestinian political parties and their continued support for violent conflict, is a persona non grata for Israel. A similar situation has also arisen for an American Human Rights Watch observer, who has been denied a "work permit" in 2017, because she planned to observe and report on human rights in Gaza [34].