In Their Words:
Mental Health Professionals in Gaza
on Treating the Effects of Closure
“There’s a clear link between the Israeli closure and the grave state of mental health in Gaza. The closure is like a drop of ink in a pool of water, spreading everywhere, touching everything.”
Nedaa Murtaja, psychologist, Gaza
For decades, Israel has enforced restrictions on movement to and from the Gaza Strip, which it tightened to the point of closure in 2007.
In August 2022, as people were still reeling from the devastation of Israel’s May 2021 attack on the Strip, Gaza’s two million residents, half of whom are children, were again subjected to a terrifying military offensive by Israel.
For years, basic infrastructure in the Strip has teetered on the verge of collapse;
electricity is available for only half the hours of the day, more than 90% of the tap water is undrinkable, and unemployment is sky-high. Repeated military assaults have further impaired living conditions in the Strip, already undermined by closure, and led to death, injury and the destruction of property and livelihoods.
But there is another form of damage, less visible to the eye: The long-term impact of the closure on mental health.
In late 2021, Gisha and the Gaza Community Mental Health Programme (GCMHP) convened a group of mental health professionals and representatives of organizations working in the field in the Strip. The purpose of the meeting was to discuss the effects of Israel’s closure on mental health, as well as the challenges therapists and care specialists face as residents living under closure in Gaza themselves.
What follows is a summary of the observations made by participants in the discussion.
Locked up and isolated
The number of Palestinians in need of psychological care or assistance in Gaza has climbed dramatically in recent years. According to various studies, between 15% and 30% of individuals living in Gaza develop post-traumatic stress disorders (PTSD).
“This means there are at least 300,000 people in Gaza living with PTSD, and likely many more,” says Qusai Abuodah, director of resource development and public relations at GCMHP.
Pictured: Qusai Abuodah, director of resource development and public relations at GCMHP
A central outcome of the closure enforced by Israel has been a high prevalence of poverty and unemployment in the Strip. Economic hardship elevates stress levels among the general population.
Khitam Abu Shwareb, a social worker at GCMHP, emphasizes the inextricable link between people’s economic reality and their mental health. “Restrictions imposed by Israel on entry of goods and raw materials into Gaza not only disrupt entire economic sectors, they also lead to price hikes inside the Strip, with direct impact on our mental stability.”
“Long-term mental stress leads to severe anxiety disorders and further undermines quality of life, which, in Gaza, is already far from meeting accepted international standards,” Osama Frina, a psychologist at GCMHP, explains. “Anxiety sometimes transforms into physical pain and suffering. The physical suffering, added to frustration and despair, often leads people to experience deep depression, which, unfortunately, also manifests in an increasing suicide rate.”
Pictured: Osama Frina, a psychologist at GCMHP
“The depression experienced by residents of Gaza is not depression in its classic, conventional sense,” says Hassan Zeyada, a psychologist at GCMHP.
“Palestinian depression is different. Gaza’s entire society is in a constant state of high level of chronic stress and ongoing trauma. The Israeli closure and travel restrictions on Gaza affect everyone, without exception. The prevailing feeling among Gaza’s population is one of helplessness and hopelessness. This situation did not appear out of thin air: It is the result of a deliberate process designed to induce a state of helplessness to weaken the resilience of both individuals and society in Gaza.”
Mental health experts describe life under closure as an experience of continuous attrition, which elicits strong feelings of frustration and powerlessness.
“You lose control over your life because you can’t make decisions for yourself,” says Zeyada. organization in Gaza. “It's like the twisted relationship between a prisoner and the guard who holds the keys to his cell. The guard is the only one who can decide whether to let you in or out. He decides whether you receive medical treatment or get to see your family. All the prisoner can do is wait. Over time, these feelings impact a person’s motivation to even try. If all attempts fail, you eventually lose hope.”
In the reality of life in Gaza, the symbiotic connection between body and mind also expresses itself in increased physical illness. “When we see conditions like diabetes and hypertension beginning to appear in young people in their twenties, it is impossible not to draw the connection to people's dire mental state,” Zeyada explains.
It’s a vicious cycle: The mind impacts the body, and the body impacts the mind. The ultimate outcome is depression and despair.”
Pictured: Hassan Zeyada, a psychologist at GCMHP
No quiet in Gaza
Aside from the everyday adversity of life under closure, the repeated military offensives by Israel have drastic psychological implications for Gaza’s residents. “The seemingly endless wars make everything worse,” says Frina. “People in Gaza live in constant fear of another war.”
Abeer Jomaa, a Mental Health and Psychosocial Support Network specialist, emphasizes an important distinction between long-term stress – like that caused by the ongoing closure – and short-term stress, mainly experienced during war.
The underlying, long-term stress is caused by decades of sweeping and systematic restrictions on movement imposed by Israel. “It is particularly prevalent among young people who are having trouble finding employment and feel they have no way of caring for their families,” she says. “This can lead to depression, apathy, chronic fatigue, drug addiction and suicidal tendencies.”
Short-term stress is an added form of pressure, experienced primarily during hostilities, and manifesting in symptoms and disorders such as insomnia, anxiety disorders, PTSD, night terrors, and bedwetting, especially among children.
“In times of war, people, including children, are in a state of existential angst – ‘Will I survive?’ ‘Which members of my family are going to die?’ ‘Who will stay alive?’” Jomaa explains.
“In Gaza, even when these anxieties begin to somewhat dissipate, we go back to the depression and other effects induced by long-term stress.”
Pictured: Abeer Jomaa, psychologist, Gaza
“Feelings of fear, stress and anxiety were amplified greatly in the May 2021 war, which lasted 11 days,” says Manal Herbawi, a psychologist at the GCMHP.
“We too, people working in the mental field, are affected by the military assaults and the destruction that ensues. Before I am a therapist, I am a mother. My main concern during the war was my inability to protect my children and give them a sense of security. I couldn’t provide the people closest to me a feeling of safety because of the very real danger coming from every direction, with nowhere safe to run to. So it's not just the patients we meet at our clinics, it's us too, as residents of Gaza, we face the same difficulties.”
Herbawi recalls a recent case – a young man who was wounded during the war and developed a drug addiction. “He tells me ‘I’m addicted, and I use drugs regularly. How can you help me? What can you do?’ He has chronic pain, and Israel won’t let him out of Gaza to get the surgery he needs. The platinum rod they put in his body isn’t helping. He doesn’t know what’s going to happen to him and whether he’ll ever be able to walk again, or if the pain will ever stop. And I understand, as a psychologist, that his mental condition is caused, to a large extent, by his physical condition, which I have no way of alleviating. How can we provide holistic treatment in this kind of situation?"
“What can you tell a person you’re treating whose problem is that they can’t find work, causing them to suffer from depression and anxiety, and you know that they are prevented from making things better for themselves? To meditate? To take deep breaths? At the end of the day, they’re going to go home and still have no income. Trying to convince them to use techniques that aren’t going to change that reality feels like a manipulation.”
Pictured: Iyad Krunz, director of the “Stars of Hope” organization in Gaza, who facilitated the focus group
Working around the obstacles
Accessing professional training outside Gaza is virtually impossible under Israel’s stringent permit regime. Mental health professionals note that this makes it more difficult for them to expand their professional knowledge and keep up with developments in their fields.
“Before the closure was imposed, there were more opportunities for professional networking with other institutions, and we were able to cooperate with organizations in the West Bank, in Israel and around the world,” Frina notes. “Since the closure was tightened in 2007, these connections have been reduced or completely erased.”
“In the past, we could attend conferences, seminars and special workshops, but nowadays, it’s rare for mental health experts to have connections outside Gaza,” adds Ramadan El Helou, director of the Center for Mind-Body Medicine in Gaza.
El Helou explains that meeting with colleagues outside Gaza would help build therapists’ resilience and protect them from burnout, but most therapists in Gaza do not have the option of taking leave to convalesce due to travel restrictions.
We’re missing excellent opportunities to develop our skills and abilities, both personally and institutionally,” says Zeyada. “Restrictions on movement limit our professional development and create an overwhelming sense of stagnation among care-givers.”
Despite these obstacles, and in the face of ever-growing challenges, mental health professionals in Gaza work tirelessly to provide a variety of services and assistance to people in need.
“The Gaza Community Mental Health Programme offers psychological support and specialized therapy for men, women and children, with patients being referred by schools, hospitals, and universities, as well as people reaching out for help through our hotline," says Abu Shwareb. “We also run training for institutions and professionals such as doctors, nurses, teachers and lawyers, and work to raise awareness through social media and in workshops open to the public."
Eroding hope
With no change on the horizon, therapists in Gaza grapple with burnout, exacerbated by the feeling that psychological treatment can only go so far given the ongoing reality of closure. “Every therapist in Gaza has patients dealing with the same challenges they are,” says Nedaa Murtaja, a psychologist in the Strip. “It may be obvious, but on top of the closure and wars, therapists also face the ongoing fear that what we can do to help is futile.”
“We’re constantly working to recruit more mental health staff, but there’s always a shortage,” says Salma Elswerky, a case worker at the Women's Affairs Center in Gaza. “Working as a case manager during the war, I lost my voice and have had a very hoarse voice ever since. I feel I don’t have the time or capacity to take care of my own mental health.”.
Pictured: Salma Elswerky, a case worker at the Women's Affairs Center in Gaza
Because the reality of life in Gaza today can seem unchangeable, mental health professionals contend with ongoing doubts. Though the critical services they provide can mean the difference between life and death, Israel’s persistent policy of closure and repeated military offensives constantly regenerate trauma, scarring a generation of Palestinians who were born into closure and have lived their whole lives under lockdown.
The adversities of life in Gaza are not an immovable fact.
“The state of mental health in Gaza could improve drastically with a single political decision by the Israeli Occupation to remove the closure and allow freedom of movement,” Zeyada says. “Removing the closure would have immense impact on people's mental health because then, at least, we would have hope.”
Photo credits: Activestills | Amjad Elfayomi | Majdi Fathi | Mohammed Zaanoun
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