Professional and interprofessional cross-cultural ethics in trauma recovery programme implementation by UK professionals in the Middle East
Professional and interprofessional cross-cultural ethics in trauma recovery programme implementation by UK professionals in the Middle East
Abstract and Keywords
This chapter contributes to the emerging field of interprofessional ethics by exploring interprofessional moral issues involved in a cross-cultural trauma recovery project set within the occupied Palestinian territories. The National Child Traumatic Stress Network framework for assessing the cultural sensitivity of recovery programmes is adapted to explore an integrated understanding of the interactions between interprofessional and cross-cultural challenges. The framework includes moral principles, social history, cultural beliefs about trauma, symptom expression and trauma recovery, language and interpretation, and personal and organisational factors. The project highlights the centrality of seeing the world through the eyes of the other, principled individual and collaborative action and long standing relationships of trust in overcoming the morass of potential interprofessional cross-cultural barriers. Recommendations are made for future research in interprofessional cross-cultural ethical programme implementation and evaluation.
This chapter, a part of Part Five (see Figure 1.1), explores the dynamics of professional and interprofessional ethics when working across countries with significant cultural differences. It uses the case study of a trauma recovery programme delivered by UK professionals in Palestine to illustrate the potential tensions and dilemmas. The chapter then takes an ethical decision making (EDM) approach to suggest ways of resolving any issues inherent in such work.
The occupied Palestinian territories (oPt) are a dangerous place for children and adolescents. A recent survey found that children in Nablus experience on average at least 13 different types of war event (Barron et al, 2013). These events include witnessing the death, injury, detention and torture and/or abuse of someone close to them, be it family member or friend, or experiencing similar events themselves. Similar to other studies, higher levels of domestic violence were found, as compared to non-war contexts (Al-Krenawi et al, 2009). Srour (2005) observes that children in Palestine live in a multi-traumatic environment that includes not only the events of violent military occupation but also the impact of trauma on the adults who care for them. In short, trauma is fracturing the protective shield of childhood in this part of the world (Punamäki et al, 2001).
The consequences for children and adolescents are many, complex and enduring. Along with a high rate of post-traumatic stress disorder (PTSD) – as high as 65% – high numbers of children experience depression and traumatic grief. Children display (p.234) difficulties in school, including motivation and concentration problems and relational difficulties with parents, peers and teachers. Zakrison et al (2004) conclude that children under occupation in Palestine display complex symptoms more akin to developmental trauma than PTSD.
In addition to war events, children's lives are negatively impacted by the deteriorating economic, social and health conditions of the occupied territories. Shortages of water, food and medical supplies; intermittent electricity; restrictions on movement; and the creation of imprisoned towns all add to the stress and trauma of living on a day-to-day basis (UNWRA, 2009). High levels of adults are unemployed (UNICEF, 2011), and those in work do not always have the guarantee of being paid; for example, prior to the current project starting, teachers in schools had not received salaries for a six-month period. During a recent seminar at the University of Dundee, Ghassan Abdallah argued that in addition to the war on water and land, these factors equate to a war on the morale and spirit of the Palestinian people. For example, numerous studies record high levels of maternal and childhood depression (Espie et al, 2009). It was this latter finding that led mental health professionals to seek support from psychologists beyond Palestine, in order to capacity-build child trauma recovery interventions.
Project Aims and Personnel
The current project was a direct response to this request for capacity building (see Table 15.1 for project summary). The project's aim, in the long term, is to create indigenous self-sustaining, high-quality trauma recovery services for children and adolescents throughout the occupied Palestinian territories. This chapter focuses on the first phase of the project, which sought to train a cohort of mental health professionals to deliver an evidence-based trauma recovery programme for children in Palestine. For the first time, a group-based trauma recovery programme was delivered to children ‘during’ on-going occupation and military violence (Barron et al, 2013). The project involved the training of school counsellors (social workers and psychologists), the delivery of a trauma recovery programme to children and the implementation of evaluative research. Nablus was the town selected for the project because of the high levels of military violence resulting from the occupation. The project involved an interprofessional group of psychologists and social workers from Europe and the Middle East. Because of the complexity of interacting factors, that is, a context of violent occupation, cross-cultural interprofessional working and the building of trauma recovery (p.235) services for children, a clear ethical framework was required to underpin project decision making (Loxley, 1997).
Table 15.1: Project - Child Trauma Recovery in Palestine
Nablus, Occupied Palestinian Territories
Responding to children traumatised by military violence within a context of inter-professional culturally sensitive practice
To capacity build school counsellors in delivering an evidence-informed trauma recovery programme for children screened for PTSD
Principal researcher: Dr Ian Barron, University of DundeeCo-researcher: Dr Ghassan Abdallah, Centre for AppliedResearch in Education, RamallahTrainers: Dr Patrick Smith, Chair, Children and WarFoundationDr Unni Haltne, Centre for Crisis Psychology, Bergen
Children and War Foundation's Teaching Recovery Techniques programme (TRT). Five sessions focus on alleviating the symptoms of PTSD
Three days training for 20 counsellors
Randomised Control Trial
Framework for Understanding
In order to understand the complexity of EDM (see Chapter One) involved in implementing an interprofessional cross-cultural trauma recovery project for children in occupied Palestine, an adapted framework from the National Child Traumatic Stress Network (NCTSN, 2006) was utilised. This framework was initially developed to assess the cultural sensitivity of trauma recovery programmes. The focus of the framework has been developed to explore an integrated understanding of the interactions of interprofessional ethics and cross-cultural working. The adapted framework, which includes the addition of ethical principles, explores (1) a socio-historical understanding of the interaction of cultures of Middle East and West; (2) the differing conceptualisations of the nature of trauma recovery and the impact of culture on symptom expression; (3) the differences in language and (p.236) interpretation; and (4) the personal, organisational and interprofessional ethics in engagement, project delivery and evaluation.
Clark et al (2007), in relation to interprofessional working, define ‘moral principles as general guidelines for behaviour based on established ethical concepts considered essential for maintaining human relationships and communities’ (p 593). In the West, and noted in Chapter One, the moral obligation for professionals to do what is good and right is frequently enshrined in codes of ethics, be they implicit or explicit. Typically these include codified behaviours, frameworks for decision making and the identification of appropriate methodology as well as the need for appropriate qualifications, on-going professional development and supervision (Clark et al, 2007). Interprofessional codes (for example, Sharland and Taylor, 2007) aim to enable professionals to collaboratively think through, and respond to, messy and changing contexts in order to get the best for service users.
The effectiveness of interprofessional codes of ethics, however, is highly contested. What is good and right, and who decides this, is open to debate. Some authors argue that codified practice can lead to the deskilling of professional judgement, intuition and analysis (Sachs and Mellor, 2003). Workers can experience ‘disjuncture’ where agencies' vested interests direct workers to hold rigidly to procedural protocols that run counter to diverse responses for diverse problems (see Fenton, 2012, and Chapter Six). Ironically, codes of ethics applied in this way can lead to the very thing that the codes were set up to avoid, that is, the harming of service users. Where codes of ethics are applied less rigidly, as guiding principles, they then become subject to differing interpretations. The interactions of interpersonal, professional, interprofessional and legal interpretations can combine to undermine rather than facilitate collaborative practice (Melia, 2001). Ambiguous roles, lack of awareness of other agencies' strengths and weaknesses, differing perspectives on the service user, power plays, vague or non-existent communication and uncertainty as to how to deal with interprofessional conflict are all examples of interprofessional challenges (Seedhouse, 2002). It is rather surprising, given the significance and complexity of interprofessional ethics, that the field is still in its infancy (Clark et al, 2007). This chapter contributes to this emerging field through the analysis of personal, professional and interprofessional ethics within a cross-cultural context.
(p.237) While literature on interprofessional ethics is emerging in the West, the same cannot be said for the Middle East, at least not in English-language papers. Where literature does exist, the emphasis tends to be on a more communal and familial understanding of how professions relate to each other (Barber, 2001). This is in direct contrast to the individualistic, managerialised and codified orientation of Western professional ethics. In the Middle East, models for understanding interprofessional behaviour tend to rely more on relational communitarian frameworks (Triandis, 1996). For example, expectancies, not expectations, are established through narratives which affirm established cultural beliefs about the position of professionals and multi-agencies within a familial society and how they relate to each other.
The interaction of such differing conceptual frameworks of what personal, professional and interprofessional ethics means between East and West is problematic for a project set in a cross-cultural context. In addition to the myriad of challenges of interprofessional working come the myriad of challenges within cross-cultural understandings. These latter challenges are, however, well documented and include differences in language, cultural or religious beliefs, the conception of what the problem is, the understanding of what children, adolescents, family and community means, and the differing conceptualisations of healing and recovery (Miller, 2006). All these cross-cultural issues can undermine the best of intentions. Add in the barriers encountered within interprofessional practice, and a myriad of worldviews both within and across personal and professional groups and cultures potentially contest for dominance (Irvine et al, 2002). Effective delivery and evaluation of trauma recovery programmes within this kind of context seems daunting, if not impossible. The current project that this chapter explores suggests that such practice can be both possible and effective.
Any ethically principled contribution by the West into the Middle East needs to be set within a complex of historical, religious, social, geographical and political factors. Historically, Britain in the Middle East is known for its colonial practices across the world, the harms these have caused, as well as the damaging legacies left behind (McLeod, 2000). Even in recent history, Britain was central in the creation of the State of Israel. The signing of the Balfour Declaration by a general in the British Army in 1917 set the scene for Israel's nationhood. This, however, was followed by the ‘betrayal’ of the Palestinian people in 1946, (p.238) who had also been promised their own state (Farsoun and Naseer, 2006). Arguably, Britain, the chief architect of the Declaration, could be seen as culpable for establishing the context for entrenched conflict in Israel and Palestine. The authors of this chapter can affirm that such insights have not been missed by the Palestinian people.
Because of this negative sociopolitical historical lens, the UK professionals in the current project needed to be sensitive to how their ‘position’ was perceived both within and beyond the project. It was important, if the project was to be accepted and leave a sustaining legacy, that the professionals from the West were seen as supporting, not leading. That is, it was Palestinian psychologists and social workers who were setting the goals and making decisions about what would fit within Palestinian professional culture. An example that underlines the significance of this issue is the occurrence of ‘unethical’ practice of some European professionals who parachute into Palestine, deliver their therapies and then leave. From discussions with Palestinian professionals and service users, the consequences of such practice are a sense of abandonment and deskilling. In contrast, the current project sought to utilise the dynamics of capacity building, whereby local professionals are skilled up and empowered to take responsibility for the change. While the details of this relational process are discussed later in the chapter, results from the original study (for example, counsellors' reports of increased competence) indicate that practice grounded in explicit ethical principles is also highly effective practice (Barron et al, 2013).
While the project had anticipated sensitivities created by recent history, the influence of distant history on personal and interprofessional cross-cultural interactions was less obvious, at least to Western minds. The differing lengths of long-term cultural memories between Middle East and West were an intriguing discovery. Going further back in time, then, the UK played a major part in the crusades in the Middle East. While it may seem out of time for Western minds to mention this, through Middle Eastern eyes such atrocities remain in current discourse. In case we resign such concepts to history and the Middle East, the team were reminded by a Palestinian colleague that it was only recently that a leader of a Western power referred to a ‘crusade’ as mayhem was unleashed on the Iraqi people as part of a so-called ‘war on terrorism’. Further, the current UK government's inaction in response to the plight of Palestine is easily construed as at best, neglectful and at worst, collusive with Israel. Within an occupied Palestine these are powerful factors, well beyond the usual discourses of personal, professional and interprofessional ethics.
(p.239) For the Western professionals on the team, the context was one of being aware of the potential suspicion from Palestinian professionals, not only because of past Western abuses but also because of the current relationship between Israel and the UK, and the widespread use of western Intelligence services in the region (Brynjar, 2007). For all these reasons, an EDM approach, based on decentring and the empowerment of the other, involved establishing long-standing relationships of trust built on Palestinian professional choice and control. Active dimensions of this empowerment included understanding the Palestinian professional mindset, being led by Palestinian goals and processes; ensuring Palestinian choice in what programme was to be developed, where programmes would be delivered and the nature of evaluation. Ethically, Palestinian decision making was therefore built into the fabric of interactions. The consequence was high levels of project ownership and continuing collaborative development over many years. The project is now in its third planning phase.
Trauma, Symptom Expression and Trauma Recovery
In addition to understanding the influence of history and international politics on how Western professionals can be construed, the project had to consider professional cultural differences in understanding the nature of trauma recovery. Not to do so would have been to mirror the insensitivities of the past. An EDM approach, therefore, supported not making assumptions based on Western perspectives, that is, an individualistic view of trauma that leads to mostly individualised therapeutic responses. In contrast, Palestinians hold a communal view of trauma, emphasising the impact of trauma on the whole family and community (Barber, 2001). As a consequence, solutions are more focused on families or communities. From an EDM, principled perspective, the project sought to ‘fit with’ rather than be counter to the local culture. As a result, an evidence-informed ‘group-based’ community programme was identified and chosen by the Palestinian psychologists for implementation. In addition to being a more culturally attuned response, a community-based intervention fitted better with the small number of trauma therapists in the West Bank.
As well as a professional ‘communal trauma’ perspective, religious thinking has had an impact on the conceptualisation of trauma for Palestinian society. A deterministic view of reality in Islam, for example, frames the traumatised child's experience in the hands of Allah. Some authors argue that such a view reduces a child's (and support adults') responsibility for change (Hammad et al, 1999). A fundamentalist (p.240) religious perspective sees the trauma response as ‘evil spirits’ that require spiritual rather than psychological intervention, for example, driving out demons. On the upside, as the problem is seen as coming from outside the child, from an Islamic worldview, no stigma is attributed to the child. However, traditional belief does attach a taboo to mental illness. Palestinian children who show behavioural signs of distress are construed as mentally ill and are stigmatised. Any child going to see a therapist would be labelled as crazy. As a consequence, children in Palestine tend to show more embodied/physical symptoms, as compared to children in the West, because these are seen as acceptable as signs of evils spirits.
It was important for the Western psychologists to understand these traditional views that permeate parts of Palestinian society. As well as helping to make sense of the difference in symptom expression between Middle East and West, this cross-cultural understanding shaped the nature and content of training provided for school counsellors, parents and teachers. The challenge was to acknowledge and respect religious and cultural beliefs while also introducing a different perspective to helping children who have been traumatised. The TRT's (Teaching Recovery Techniques) programme emphasis on normalising symptoms and externalising traumatic events as the cause provided a new yet familiar message that the problem was located outside the child and therefore not connected to mental illness and stigma. Trauma was reframed as a natural response to exceptional circumstances. This was a congruent message for psychologists, social workers, teachers and parents where the child's behavioural and emotional expression of trauma was reconstrued as ‘natural’ rather than a sign of being ‘crazy’. Evaluative feedback from school counsellors indicated that this reframe embedded well into the Palestinian mental health professional recovery narratives (Barron et al, 2013).
Along the same lines as the taboo on behavioural signs of distress, children in Palestine do not have the same rights of self-expression as those given to many children in the West. Self-expression for children is seen as being within the domain of the family and is discouraged with strangers. This is due in the most part to an honour culture, where family reputation is foremost. The result for children is that they find it difficult to share in school and community settings, as this is construed as a betrayal (Dwairy, 1998). Training for counsellors therefore had to address counsellors' own feelings in enabling children to share, as well as considering how comfortable they felt in their response to hearing children's self-expression about, for example, daily family life. Within the context of training, this was achieved through non-directive learning (p.241) activities where counsellors made their own choices about enabling children's self-disclosure as well as their own ways of responding to children.
Another aspect of cross-cultural interprofessional EDM experienced by the project was grasping the difference in conceptualisation of trauma recovery programmes by psychologists and social workers, regardless of country. Social workers tended to hold more sociological perspectives regarding the focus of programmes, for example, intervening in families and whole communities, whereas psychologists' tendency was to seek to impact on within-child factors such as reduction of symptoms, growth of self-confidence and so on. These conceptual differences also lead to differences in programme focus, for example, some programmes in Palestine aim to build community resilience while others focus on the self-control techniques. Further, trauma recovery interventions in Palestine tend to be far less protocol oriented, as compared to the programme-driven mindset of Western psychology. In order to be respectful, the project sought to incorporate these differing conceptualisations. This provided the opportunity for more flexibility in programme delivery than had hitherto been planned. Although the TRT programme is protocol based, training involved helping the counsellors to explore how to adapt the programme within theoretical guidelines as well as how to help counsellors to consider developing the contexts in which the programme was being delivered – for example, teacher and parent responses to traumatised children. In order to monitor this aspect of programme development counsellors were asked to record the nature of their programme adaptations and why. Interestingly, however, most of the issues reported centred not on conceptual differences but on the nature of responding to children's distress levels and their developmental understanding of the programme. Perhaps debates about theory become secondary in the immediacy of responding to a child's distress?
Language and Interpretation
The differing conceptualisations of trauma and trauma recovery by profession and culture were underpinned by the nature of language and communication. Some of the discovered differences in language included cultural/linguistic understandings (what ‘adolescence’ means), interprofessional language and terminology (codes of practice) and the use of specialised words (emotional regulation). These issues were relevant at multiple levels of engagement, that is, across the interprofessional planning team, to school counsellors and with the (p.242) adolescents receiving the programme. To address the ‘confusion’ of language, the project members adopted an awareness of the need to seek permission and check out shared understandings. This process was facilitated through the use of an interpreter, who was a Palestinian psychologist and one of the project leaders. Educated in both the Middle East and the West, the interpreter was well placed to identify and name subtle, unnoticed misunderstandings.
Interpretation involved translation of the training materials, the TRT programme, evaluation materials and ‘live’ interpretation of the English-speaking presenters at the training workshop. EDM issues included trusting that the translation was accurate and the need for the trainer to be active and check out what counsellors said in response to questions (Minas et al, 2001). The team recognised the importance of acknowledging the feelings of the interpreter, trainer and researcher present at the training. Apprehensiveness was seen as a normal response for all concerned. School counsellors experienced a degree of uncertainty in discussing their feelings because these were being translated and heard by a psychologist and researcher who were ‘foreigners’ and, for some, from a different profession.In order to enable trust to develop, additional time was taken, which slowed the pace of training sessions. Frequent checking of understanding by all was encouraged and the complex process of dealing with word meanings in two languages and two professions was acknowledged and respected, for example concepts such as family, child, trauma recovery etc. (Minas et al, 2001). There was a need to discuss how language was changed by interpretation and to acknowledge that what was important to one culture might not be for another. For example, what ‘refugee’ means to a Palestinian social worker has a different meaning to a psychologist from the West: for example, a communal understanding of being a refugee in one's own land, as compared to an individualistic understanding of a refugee seeking therapy following escape to another country.
Personal and Professional/Organisational Factors
Beyond professional, cultural and linguistic understandings, an EDM perspective highlighted the need for the project to be attuned to a range of personal and professional/organisational circumstances that could impact on the project's effectiveness. For example, school counsellors who were to receive the TRT training brought differing levels and foci of knowledge and skill, personal experiences of trauma, economic circumstances, other work demands, the challenges of travel (p.243) and permit restrictions and training expectations. For the project to be EDM congruent these circumstances required to be considered.
As noted previously, most school counsellors were graduate psychologists and social workers. Most were under 25 years of age. While counsellors held a good range of theoretical knowledge, they tended to lack the practice frameworks for applying their knowledge in the area of child trauma. Irrespective of discipline, the project needed to be attuned to this transition from theory to practice and to monitor how this was progressing. Further, the training programme had to provide counsellors with ways to help them cope with their own trauma symptoms; for example, the teaching of reframing and coping skills. In the same vein, evaluation had to take account the high levels of counsellor trauma exposure and the impact on levels of attrition. The project was also aware of the harsh economic circumstances of the professionals and the challenges of even getting to the training; for example, the high cost of living, coupled with low salaries. Stipends were therefore provided for counsellors, along with travel and subsistence costs to ensure that participants were able to attend.
A new discovery was Palestinian professional expectations regarding the nature of training, that is, Palestinians are used to long days of training and the provision of high-quality packs. To meet expectations of what ‘good’ training is, both were incorporated into planning and delivery. Further, the engagement of the counsellors was partly based on the reputations of the organisations involved, that is, CARE, the Children and War Foundation (CAW), the University of Dundee and a local interprofessional syndicate in Nablus. All were perceived as credible. At a more personal level, there was recognition across the project that the professionals involved recognised in each other a track record of moving to action to assert the ‘other's’ human rights (Beauchamp and Childress, 1994). Interestingly, the restating of this value base provided an effective strategy for overcoming differences in understandings encountered within training and during project planning.
Personal and professional/organisational factors not only had to be understood and responded to but also played a part in the creation and maintenance of a culture of EDM throughout the project. Professionals were in the project not because their organisations expected them to be there but through a sense of choosing to be there, in some cases despite their organisations. This was personal and professional value-based commitment that involved training during holidays and self-funding. Further, these professionals were mostly unfettered from organisational agendas with regard to day-to-day decisions – they were, in essence, (p.244) co-creating their own structures, processes, communication and culture around the goal of providing child trauma recovery programmes.
The current chapter has applied an adapted culture-sensitive trauma recovery framework to understanding the ethical factors embedded within an interprofessional cross-cultural project. In overcoming the morass of potential personal, professional and interprofessional cultural barriers, the project highlights the importance of (i) seeing the world through the eyes of the other, (ii) explicit principled action, and (iii) long standing relationships of trust. A clear EDM model is seen as fundamental to the success of the project. Learning from, rather than repeating, the mistakes of the past, taking the time to understand how the other sees and experiences their world, a concern for communicating ethically, adapting initiatives to ‘fit’ local experiences and supporting the decision making of the other, all appear to be factors in facilitating effective ethical interprofessional cross-cultural practice.
This chapter is exploratory and discursive in nature. It does, however, highlight a series of questions relevant for the development of future research and practice in the field of interprofessional ethics in cross-cultural contexts. There is a need for:
• greater clarity of definition of what makes interprofessional ethics distinctive within a cross-cultural context, as compared to single-country settings;
• the development of a coherent theory to bridge interprofessional and cross-cultural ethical understandings;
• the development and systematic application of this chapter's framework to other interprofessional cross-cultural contexts;
• the assessment of the perceptions of workers across professional projects in order to gain a deeper understanding of the ethics underpinning their interprofessional cross-cultural practice.
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