In Gaza's mental health crisis, no respite from the cycle of trauma

She came out screaming: “Enough! Enough!”

Only to drop dead immediately after she had uttered those words.

Her name was Amany. She was my cousin.

Thirty days and 30,000 tonnes of bombs later, Amany had exhausted her last shred of endurance. Her heart gave in and she died at the young age of 42.

Only four relatives, not including her husband and only brother, could take her to the graveyard for burial, for danger is everywhere on every street of Gaza City. For the Israeli pilots peering down, there are no exceptions, humanitarian or otherwise.

No room for interment, no time to mourn, and certainly no time to grieve.

You may think of this as a sad speck on the large canvas of the ongoing Gaza tragedy. It might be, and here I choose to depersonalise the situation.

"In Gaza, parallel to the physical death, there is always the psychological one. The first is instant elimination - 'immediate relief' as someone put it - while the second is slow disintegration that can be life-long and, for some, simply a deferred death sentence"

But, Amany’s death is symptomatic of another horrifying Gaza reality invisible to the naked eye, hidden away inside the fog of war. It is the tragedy of trauma, the breakdown of an entire population’s mental health, 2.2 million of them.

In Gaza, parallel to the physical death, there is always the psychological one. The first is instant elimination - ‘immediate relief’ as someone put it - while the second is slow disintegration that can be life-long and, for some, simply a deferred death sentence.

This means that even when the sky stops raining down bombs on Gaza’s inhabitants, the war within the soul of every Gazan will continue to rage, most likely at a greater level than any time before. “Sadness on fire” is one of the new terms I started to hear from people in the Strip over the past weeks.

To be ‘sad on fire’ is to have experienced a cumulative and progressive impact of repeated and prolonged traumas.

Palestinian children in Gaza are experiencing a whole host of signs and symptoms of trauma including anxiety, fear, nightmares and disturbing memories, insomnia, bottling up emotions and withdrawing from loved ones.

Read more: https://t.co/xl6rQvP3Rj#Gaza #Gaza_under_attack pic.twitter.com/0krOcyv5vZ

— The New Arab (@The_NewArab) November 8, 2023

Well before this annihilative war, Gaza had already been suffering from record levels of mental health problems.

Seventeen years of blockade, multiple rounds of violence, four wars, poverty, and shortages in basic services  - all built on top of 75 years of transgenerational scars - have left most people with varying degrees of trauma and mental health issues. It is particularly dire for children, who represent nearly half of Gaza’s population.

Not until 2009 did the Gaza mental health situation begin to attract serious attention, despite various previous studies. That year, renowned Palestinian psychiatrist and the founder of the Gaza Community Mental Health Programme, Eyad Sarraj, produced a documentary titled On Gaza’s Mind.

In it, he blamed Israel - by design of its occupation - for injecting helplessness into Gazans to trap them in an existence of fear and psychological paralysis.

2009 marked the end of the first Israeli ‘war’ on the Strip, where nearly 1200 people were killed. It was only two years after Israel’s ‘official’ siege commenced. It was also four years after the end of the Second Intifada, which saw the death of nearly 4000 Palestinians.

2009, in other words, was a pivotal year that perhaps saw the maturation of a fresh, collective psychological pattern in the Strip.

Dr. Sarraj died in 2013, a year after the second Gaza ‘war.’ The traumatised children and adults whom he helped - at least the ones who have physically survived the multiple onslaughts since - continue to live through the cycle of traumatisation today.

What I am talking about here is a ‘traumatic loop’ that keeps on giving without respite or pauses. The closest to respite would be periods of low-intensity Israeli aggression sandwiched between its mass bombardment campaigns every few years.

To put it in perspective, the average Palestinian adolescent in Gaza turning 15 today will have experienced five wars; repeated loss of hundreds of lives and livelihoods including family and friends; temporary displacement; and the physical destruction of neighbourhoods and infrastructure.

According to studies, this has for most translated to severe post-traumatic stress disorder (PTSD) typically characterised by disrupted sleep, being constantly on the edge and easily startled, flashbacks, nightmares, and emotional numbness.

This is certainly true for the Gazans I met and mingled with in the UK, especially those freshly out of the Strip. The mere chuffing sound of a police helicopter or fireworks would have sent them into a sudden jitter. Nightmares about being trapped in Gaza, stuck on the Gaza-Egypt border, or chased by Israeli missiles, are also very common.

“Strangely, I did not experience such intense nightmares when I was under bombardment, they only started in the UK,” I was told by one of them.

Perhaps an expected delayed reaction. In Gaza, facing real danger, most people would cope by entering a fight-or-flight mode, a state of hyperarousal in response to perceived harm.

"But to call it a post-traumatic stress disorder for those Gazans who are still trapped in the ongoing trauma is to misinterpret, and even trivialise, the situation. It is something else. There is nothing 'post' about the trauma"

Once they are removed from the actual danger, the crippling traumas that they had suppressed and allegedly tamed for survival purposes start to rise to the surface when one’s guards are down. It manifests as nightmares, flashbacks, and displaced anger, among other things.

But to call it a post-traumatic stress disorder for those Gazans who are still trapped in the ongoing trauma is to misinterpret, and even trivialise, the situation. It is something else. There is nothing ‘post’ about the trauma.

Shall we call it ‘ongoing traumatic distress disorder’? It is where fight-or-flight is normalised; for everyone to be on high alert incessantly without relief.

Be it a necessary survival mechanism, fight-or-flight is meant to be only a temporary defence strategy against an abnormal but short-lived situation. Studies show that even those - children and adults - who seem to become desensitised to the violence around them (coping through apathy and normalisation) remain deeply scarred. To make matters worse, professional therapy is limited in the besieged Strip.

The mental health impacts of Israel’s apartheid regime has already been detrimental to the Palestinian people. But the recent violent attacks on Gaza will lead to further unimaginable generational trauma, writes psychologist @NasreenHanifi 👇 https://t.co/brnx386Kd3

— The New Arab (@The_NewArab) October 31, 2023

In the language of statistics, a 2022 report found that four out of five children in Gaza lived with depression, grief, and fear. Compared to 2018, according to the same report, the mental well-being of young children, along with adolescents and caregivers had deteriorated significantly, increasing from 55% to 85%.

For children especially, the emotional distress was externalised as increased aggression, high anxiety, bedwetting, nightmares, flashbacks, and poor school performance.

The results of the blockade, such as the electricity issues, especially when combined with other stress issues in the Strip have also had dire consequences on Gazans’ mental health. A study from September 2023 by the University of Birmingham on the impact of power cuts in Gaza found that 93% of the 350 families surveyed suffered from moderate-severe or severe anxiety - compared with 6% within the general population in Palestine. Some 44% of individuals suffered from moderate-severe or severe depression - compared with 5.6% in the general population.

Additionally, as of June 2023, the World Bank reported that 71% of Gazans showed symptoms associated with depression, compared to 50% in the West Bank. Earlier reports showed that because of the overall desperation and hopelessness, 38% of young people in Gaza considered suicide at least once.

This is a novel phenomenon for a society typically characterised by high religiosity and a close-knit family system that traditionally acted as a buffer against this level of mental health deterioration.

Palestine is generally a psychologically fatigued society and for obvious reasons. For Gaza, it is those reasons and more. It is a community struggling to survive through a genocidal war fitted within a siege, that within a military occupation, and all within a settler-colonial regime.

Each one of these oppressive layers has its own political and socio-economic ailments, as well as its unique psychological repercussions. Combine them all, and Gaza may have the world’s most severe mental health crisis.

The bigger question that I now dread to ask is: what will a society already burdened with a near-collapse psychological state look like after this seemingly annihilative war?

Dr Emad Moussa is a Palestinian-British researcher and writer specialising in the political psychology of intergroup and conflict dynamics, focusing on MENA with a special interest in Israel/Palestine. He has a background in human rights and journalism, and is currently a frequent contributor to multiple academic and media outlets, in addition to being a consultant for a US-based think tank.

Follow him on Twitter: @emadmoussa

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Opinions expressed in this article remain those of the author and do not necessarily represent those of The New Arab, its editorial board or staff.