Palestinian children on the streets of Deir al Balah. Photo: UNICEF.
A ten-year-old boy hasn’t spoken or eaten in days. When our psychologist finally gets him to talk, he asks a question that stops her cold: ‘Everyone says my friend went to heaven, but I didn’t see his head. How can he go to heaven without his head?’ This is mental health work in Gaza today.
How do you provide mental health care to people being annihilated? It’s a question I’m asked constantly as a psychiatrist in Gaza, and one that haunts every interaction I and other clinicians have with the children and families we serve. The answer, I’ve learned after 20 months of genocide, is both simpler and more complex than anyone imagines.
In my 20 years as a mental health professional in Gaza, I thought I understood trauma. Then came October 2023, and everything I knew about healing, resilience, and hope was tested against a machinery of annihilation that operates 24 hours a day, 365 days a year.
Mental Health and Forced Starvation
Nowadays, when we speak about mental health in Gaza, the main concern is the extreme worry of parents about their children’s general health after almost 20 months of deprivation of essential nutrients and now the absence of basic food. Families now prioritize who will eat today and who will not. At best, children receive one meal per day, and that meal lacks basic necessities like fruits.
Flour, the main ingredient in our daily meals throughout the Middle East and Palestine, is almost unavailable. Bread has become a memory. Now, families attempt to make bread from pasta. At least they put something in their mouths simply to cut hungry feelings.
The mental health impact of this long exposure to multiple traumatic experiences extends far beyond the catastrophic continuous bombardment that keeps children terrified and feeling on the brink of death at any moment. Multiple displacements, as families are forced to move from one unsafe area to another add new layers of hardship. In a harsh environment where 80 to 85 percent of houses and infrastructure lie destroyed, a child looks around and sees only destroyed homes, destroyed schools, and everything around them in ruins. How can they walk around? How can they think about a better day?
People say our children look numb – they are not responsive. For months we have heard about children becoming aggressive, having problems with each other, a form of expressing rejection. We are all rejecting the reality we live in, we are not happy, we are angry. And children, who are half our population, express this in very different ways.
There is a new symptom arising among adults. They feel not only angry and isolated, but unfortunately, they have begun feeling guilty. Guilty because they cannot help their children, they cannot even find food for their children. This is a strange feeling we are witnessing almost for the first time.
We add this to the usual symptoms: children being scared most of the time, problems with sleeping, nightmares, bedwetting, parents experiencing trauma like PTSD but also depression, severe anxiety, and physical pains. Those physical pains affect men, women, children, adults – everyone. It represents a variety of complex issues affecting people who have been exposed to this for 20 months, but also not for the first time. We do not speak about the third or fourth or fifth time, but multiple times since 2008, and even earlier because we have always lived under blockade, under occupation. Our lives were never peaceful, and we wake from one disaster only to fall into another.
Care in Impossible Circumstances
One thing we consistently see in people during emergencies and atrocities is their need to maintain a sense of agency – that they are accomplishing something. That is why now you see men and women constantly active: women do whatever they can to cook something for their children, men try to find any source of food here and there. And at the community level men and boys race towards every new bombed area to dig out the wounded and carry the victims to hospital on foot or any donkey cart or car. It is not an individual issue – the entire population of Gaza Strip experiences this collectively. That is why nearly every family member has a task, which somewhat masks the psychological impact on the population while simultaneously giving children roles they should not have. Kids who are six or seven years old should not be carrying bags of water and walking two or three kilometers to provide their families with drinking water or to recharge mobile phones.
This sense of agency alleviates the psychological impact. This is key when we meet people in the community – we currently have about 30 staff visiting shelters and tents, talking to men, women, and children, helping them express themselves, discuss their feelings, and receive counseling and stress management help. When there are urgent symptoms, we refer people to our community centers.
In those cases, we first ask people to look around and think about how they can help themselves and help those around them. In a way, this creates some feeling of agency that helps people move forward and think somewhat positively, if there is a chance for positive thought about what they can do.
Our teams take toys and stationery when possible, and this is a game changer. When children suddenly find they can express themselves through drawings and play, talking about the problems they face, they begin acting out – showing or discussing their fears when they draw destroyed houses, wounded people. Sometimes they draw blood, sometimes tanks. They draw what they feel, and this makes a big difference.
But of course, it is extremely difficult to help people while attacks continue. Ideally, psychological interventions begin when disaster ends or when people reach safety where mental health professionals can function like other healthcare workers or emergency workers. This is not the situation in Gaza.
Power of Expression and Healing
We emphasize that it is always important when experiencing stress to find someone to talk to – this is the simple truth. People must talk to friends, family members, colleagues, and discuss things. People can open their hearts if they can speak. For instance, if I had a terrible dream yesterday which reminded me of a house destroyed before my eyes, I talk to someone in the family or a neighbour in a nearby tent, and they share the same experience. Then there is a sense of a collective healing process.
But when it comes to children, they have different ways of expressing themselves. They are not yet mature enough to express themselves as we adults do. For example, they sometimes cannot say “we are scared, we are terrified,” but instead the child jumps from place to place, shaking or unable to stand still, becoming very irritable. Girls become very shy and isolated. Children become more aggressive – another example of how trauma expresses itself.
Here’s a story from a colleague. She visited a camp, and people told her, “Go to that tent, there is a lady whose son has not spoken for the last three or four days.” She went to that family and the mother told her, “Yes, well, it’s not only that he hasn’t talked for the last three or four days, but he hasn’t eaten anything either.” This story happened about two or three months ago when food was available – and when we say food was available, that means people had something to eat, not that they had real food.
Our colleague went and sat next to the child, who was ten or eleven years old. She had crayons and papers for drawing. She put them down and told the child, “I am a health professional, I’m here to listen to you. I heard you haven’t been talking for a while, but I am here to listen. Whatever comes to your mind, just talk to me.”
The child did nothing, said nothing. She waited, then told him again, “I am here for you.” After a few minutes, the child said, “I saw children I was playing with. They were killed in front of my eyes.”
He started to cry. A little later, she told him “they went to heaven” – something we say to children to calm them. This is what everyone says: they are in heaven, in a better place.
The child replied, “Everyone tells me that, but I didn’t see the head of my friend I was playing with. Only his body was there. How could he go to heaven without his head?”
She responded, “It’s God’s business. He is almighty and can do what is needed, and of course he can reunite the head with the body of that child.” She began comforting the child, saying, “I also heard you haven’t eaten anything. Can I bring you some food? And here are some crayons, and this bag is yours. It has toys and crayons. You can draw whatever you want.”
The mother brought food – a piece of bread with something in it – and the child started eating. He began not only to talk, but to play with the crayons and to eat.
When the psychologist shared this story at our community center, she was extremely happy because she had succeeded in getting a child to speak and eat. She spoke about how happy the mother was that the child was eating. They followed up with the child two days later and he was doing better, and they continued providing the care he needed.
Sometimes these small things you provide are very important. Sometimes you don’t realize how important they are until you see the significant change they create. With such a child, if he had not expressed what he thought about how a child could not be in heaven without his head, that would have remained a trauma with him forever.
We know trauma. Once you are exposed to trauma, the trauma remains in your psyche. You cannot erase it, but the question is: can you continue with your life? Can you process it somehow? Can you overcome it and move forward, or will it continue to harm you, to impact how you think, your capacity to concentrate, to learn new things, to continue with your life?
Today we discuss evidence-based transgenerational trauma. This is why we fear that what is happening will impact Gaza’s people not only for years, but for decades to come.
The Staggering Scale of Loss
The numbers now: the Gaza Health Ministry cites more than 60,000 people killed and more than 112,000 wounded, though research published in The Lancet suggested the death toll was 40% higher than that, taking into consideration those missing and under the rubble . Usually, not only this time but from previous attacks, at least one-third of the injured or killed are children.
We speak about 39,000 children who lost one parent. Among them, 17,000 lost both parents. The number of unaccompanied children who are the only surviving family member exceeds one thousand. Children who lost an arm or leg – children with amputations – number more than 800.
These statistics are staggering. They are for a society where before October 2023 half the population lived below the poverty rate because of Israel’s long occupation and subsequent blockade.
Imagine that those children have had no education, no schools for a year and a half, except the miraculous improvisations of Gaza’s teachers against all odds. They have not enjoyed any normal daily life during those 20 months. They live in tents, walk around destroyed places, are psychologically impacted, and see no positive signs for a better future. Not only that – bombardment continues almost every night.
Gaza Strip is about 40 kilometers in length and 8 to 12 kilometers in width. When bombardment happens in one place, everyone hears it. This is continuous exposure to traumatic events without a break that would allow healing, while living in appalling conditions not having adequate food – that enables you to stand up and walk around or run like children, to have healthy physical well-being. Nor do they have the support of the health system now suffering acutely and in crisis mode only.
Personal Losses
In 2014 our family was struck by tragedy. It was at sunset when the building was bombed, during Ramadan. It was when people sat to break their fast – around 6:00 PM after a long day of fasting for 13 or 14 hours. We were hearing the Adhan, the call for sunset prayer, the same moment when people begin eating.
We heard two large explosions simultaneously, and we knew where the bombing occurred. Later we heard the news and understood that the building with three stories had been leveled with 28 people killed, including three pregnant women and 19 children.
We spent the entire night trying to find people’s bodies. Even when we went to the mosque the next day to pray the funeral prayer, there was a large bag of bodies that were not identified or could not be separated – like everyone else, body parts were put together and placed in one grave.
It is something you can never forget. Something you must live with. I was blessed then by having many GCMHP colleagues around me, many colleagues from the international community calling, and of course family members and extended family relatives. It was one of the most reported events because of the high number of people killed in that single attack.
Then in 2023-24, many attacks killed hundreds of people. In another Ramadan, on March 18th when the ceasefire was broken by Israel and they began attacking again, they did so at 2:30 am. That was about an hour before dawn, when people were about to wake up to prepare for Suhur, the last meal before sunrise when people stop eating. Mothers were preparing whatever food they had when suddenly the loud sounds of bombardment – countless jet fighters struck Gaza at that moment, over that small geographical area simultaneously, terrifying everyone. Reports say that more than 400 people were killed during that attack, some as they slept.
Like any other family, some of my family members were also killed since October 2023 – in smaller numbers, different circumstances, but we are like any other family in Gaza Strip. Among those killed, missing under the rubble are members of each family or extended family.
In April last year, two of my cousins from my mother’s side decided to return to their house to fetch something and collect some clothes. People had nothing when they fled their houses, and there were moments when they thought they could go back and grab something. These two children – one was 17, the other 16, who were cousins – decided to return to their house just to get a few things. One was particularly interested in getting his laptop.
They entered their house which was still standing in East Khan Younis near an area called Abasan. It seems they got inside their house, collected whatever they needed for their parents and siblings, each with a backpack filled, then headed back to Rafah to the tent area. A drone killed both. Their parents could not go to say goodbye. People staying in a nearby school took the bodies and buried them.
A few weeks later, another tragic event involving people from my extended family were killed – another two young children, two brothers, one was 12, one was 15. Their only mistake was wanting better internet access, and they were in a building with internet access. The building was destroyed, bombed, and their bodies were in the rubble for hours. When they were pulled out, we went to the hospital in preparation for the burial.
I saw one of the fathers of the two children whose bodies were in the school, and he said, “Doctor, I don’t know what to say, but at least they saw the bodies of their children.” At least Ahmed (the father of the two killed brothers) could see the bodies of both his children and say goodbye to them, but my brother and I couldn’t say goodbye to our sons.
Trauma manifests in many ways, and the way people are exposed to trauma is different, but the impact is always unbearable, and we have to live with those stories. You have to survive, and that is why everyone living now in the Gaza Strip or who managed to leave Gaza Strip – is a survivor.
We speak about a survivor who spent 20 months running from one tent to another. We speak about a survivor who for 20 months only had the chance to shower five or six times – and for women this is extremely shameful. We speak about a child who has not had the chance to eat any kind of fruit for 20 months. We speak about a child who has never seen yogurt in his or her life.
Managing Anger
People are incredibly angry. I am also very angry, but over the years I learned how to manage my anger because you need to, one way or another – mental health workers mission is to help others. My other mission is to lead an organization that has the vision of a leading organization in the field of mental health and human rights in Palestine.
To continue that, we need to support our colleagues, support ourselves, know what to do, what to say, how to react. It is a very difficult job, in a very challenging context, but you learn how to do that. You learn it because there is no other way. We need to help the community, help people overcome difficult realities – I wouldn’t say cope because it’s beyond coping – but at least do something that would allow people to continue with their lives, prevent and minimize the psychological impact as much as possible. We try to work on resilience if any resilience remains. For that, you need to control yourself. That is how things are.
Mental Health and Human Rights
How can you be psychologically well when you are oppressed, when you do not exercise or practice your basic rights, when your right to health is absent, when your right to education is absent, when your right to safety is absent, when your right to peace is absent, when your social rights are not respected, when you experience daily violations of your basic rights, when your right to life is threatened daily. How can you survive that?
You cannot live a healthy life or lead a healthy life when you are under oppression. We see this in victims of gender-based violence, domestic violence, in people living under oppression. But in Palestine it is unique that we speak about something happening for decades now. We are a nation not allowed to have its own state. We are people living in the 21st century under occupation, that destroys people’s daily lives, sometimes slowly and recently often in a flash.
These continuous violations of rights impact on how people live, how they think. As mental health professionals, we deal with the implications of those violations. Some violations are clear – they are visible like what happens now when people are killed or hear bombardment. Sometimes they are subtle.
For example, look at the West Bank. There are hundreds of checkpoints dividing the West Bank into segregated areas. People who work in one city, will take sometimes hours to reach their village or small town. There are uncertainties about everything. Schools sometimes in the West Bank close because of new settler or military violence, or road closures, or town closures.
When people go to pick their olives, this is now an annual ordeal for people. Throughout the world, farmers, when it is time to collect their farm production, it is a cheerful moment – everyone is happy. But not in Palestine. People are afraid that they can be harassed by settlers, their trees burned to the ground by settlers.
How can you psychologically survive such living conditions?
The Concept of Resilience
Resilience was something nice that I talked about twenty years ago, that I was proud of – that despite all difficulties, despite closures, despite blockade, despite the second Intifada. Despite growing up in such harsh conditions, Palestinians continue with their lives. We have the highest number of educated people, the lowest illiteracy in the Middle East, the highest number per population of master’s and PhD holders. These achievements are against the odds, and the explanation for that was “resilience” – young people are resilient.
Later, I started questioning what this means. Resilience means that despite all stresses, people do not develop mental disorders. They continue to psychologically survive. Well, we are surviving psychologically, but we are enduring so many difficulties, stressful events and times that this cannot continue. That resilience will not be able to continue forever. It cannot cover the reality or make us overlook the fact that we deserve to lead a normal human life like any other humans. We are entitled to moments of joy, to days of peace, and to lead a normal life.
Palestinians are very productive people. We deserve to live like any normal people, to thrive and see our children play, see our children have fun, and move on with our lives. The word resilience is like a reminder of how many difficult days we already went through.
Hope in the Darkness
The story of my colleague psychologist who told us about her visit to the tent – and we have many such stories – these are sources of hope. The mother of that child when she saw her son speak again and eat again is another story of hope. The story of 2 million people still surviving in Gaza Strip, despite all the horrors, is a story of hope.
Hope is present everywhere. When we had the two-month ceasefire, there were many groups of children whose families started arranging some education classes in tents. That is a source of hope.
When you see people who say “okay, we lost our house, but we are staying near our home and we are going to build it again,” that is a source of hope. When you see people sitting on the roof of their destroyed place saying, “Here we are present,” that is another sort of hope.
When you see how much solidarity exists in the international community, that is another source of hope. When you see people trying to call you to check on you, that is a sort of hope.
When you see a child who lost everyone in his family but lives with another family and thinks, “Okay, I am the survivor,” and continues with his life, that is a sort of hope. Just not being broken is a sort of hope.
That is what we try to do when we meet our people in the community – we help them identify good things around them, despite cruelties and challenges, and this becomes a source of hope. Our main source of hope is how miraculous our people are and that they are standing in front of that killing, massive killing machine, and they continue trying to survive.
A Misconception
We have seen that whenever a bombing occurs, Gaza is in the spotlight, people understand what is happening. When bombing stops, people think it ends the harsh living conditions and that people continue living in peace. This is not reality.
Between 2014 and 2023 – those nine years – the blockade on Gaza Strip with movement restrictions was always present. Drones flew in the skies constantly, reminding people of disasters. At least five large-scale operations took place between 2014 and 2023, reminding everyone of what disaster meant. Thousands of people with serious health illnesses could not get healthcare outside Gaza Strip because of movement restrictions.
This life under such human rights violations is not seen by the international community. People think life is continuing, like a disaster area where once war ends, recovery happens, and people continue with their lives. That is never the case, unfortunately, with the Gaza Strip.
In one month, two months, three months, one week – another ceasefire will be reached. That is what I pray for, what I hope for. But it does not mean our life will improve immediately. The immediate threats will stop, the bombardment sounds will stop, but our children will continue living for years with the rubble. For years to come we will not be able to rebuild all the schools and houses that were destroyed. Throughout those years we will have triggers that will keep reminding us of the traumatic conditions, of the displacement and attacks, the people we have lost – our beloved people, colleagues, friends, family members who were killed during the attacks.
The International Community Must Act
In every place where war takes place, there are rules and regulations that must be followed by law. For example, the right to health, evacuation of people who were wounded or killed, hospital safety, safety for healthcare workers, allowing food in, allowing water in. These basic things – allowing things needed for women and children, hygiene items – these very basic things are never respected and were never respected during those 20 months.
Rules are universal, and Palestinian people are not an exception. It is not acceptable that leaders of the international community are just watching and just talking. They do nothing besides making announcements or statements or sending reports and taking no serious action.
It is beyond understanding. They need to be proactive; they need to take on-the-ground actions. Food is a very basic right. Medication is lifesaving.
As they fail with this, then why do we need them? What is the need for the international community, for INGO workers, if they cannot manage for two months now to get flour or milk into the Gaza Strip? What is the use of their presence?
The international community has the power to act, but they must have the will to use it.
The international community has perfected the art of watching and making statements. But children can’t eat statements. Families can’t shelter under reports. If you cannot ensure that flour and milk reach Gaza’s children, then what exactly is your purpose? Mental health professionals understand this: healing requires action, not just words. The world’s mental health depends on it, too.
So, how do you provide mental health care during genocide? You do it by refusing to accept that any people deserve to live this way. You do it by helping a child speak again, by sitting with a parent’s guilt, by finding hope in the simple act of survival itself. But mostly, you do it by demanding the world remember that Palestinians are not resilient by choice—we are resilient because we have no other option. And that must change.
When this ends—and it will end—Gaza’s children will carry these traumas for generations. But they won’t be the only ones marked by this moment. History will ask what you did when you knew. Mental health, it turns out, isn’t just about healing trauma—it’s about preventing it. The question isn’t just how we provide care during genocide. It’s why the world allows genocide to continue.
