Unbearable suffering — the Palestinian clinicians' account of what Gaza is doing to the mind

Of everything written on the mental health consequences of the war on Gaza, this short commentary is the document to read first, because of who wrote it. Its authors include Weeam Hammoudeh and Rita Giacaman of the Institute of Community and Public Health at Birzeit University, Rana Nashashibi of the Palestinian Counseling Centre in Ramallah, and Yasser Abu-Jamei of the Gaza Community Mental Health Programme, with Hanna Kienzler of King’s College London and the systemic psychotherapist Gwyn Daniel. It was published in BMJ Global Health on 30 September 2024 (DOI 10.1136/bmjgh-2023-014835) and is open access.

Its summary box states the argument without hedging: “The onslaught on Gaza is leading to catastrophic psychological consequences which will not be limited to the short term and to those directly affected, but will have long-term, intergenerational effects.” What it proposes instead of a diagnostic frame is Giacaman’s concept of the invisible wounds inside, which the paper glosses as a way “to link the biomedical sphere with the political sphere through the concept of suffering”, emphasising “socio-political conditions and the collective trauma-inducing nature of the Israeli military occupation and repression.”

The clinical observations are precise and are worth quoting exactly rather than summarising. On children: “Reports reveal that children are experiencing acute trauma responses including frozenness, mutism, convulsions, confusion and loss of bladder control.” On parents: “Parents feel that their parenting capacities are diminished because the inability to protect one’s own children is such a profoundly debilitating experience.” On the collapse of the system meant to respond: “All six Community Mental Health Centres ran out of medications and were forced to close, and the only existing inpatient psychiatric hospital was shelled and can no longer function.” On mourning: the destruction is so pervasive “that families are no longer able to carry out mourning rituals to [bid] their loved-ones farewell and to receive or extend condolences, making any form of closure extremely difficult.”

The paper is also the source of the single sentence that most sharply refuses the therapeutic framing of a political catastrophe. Its authors quote their own co-author, the counselling psychologist Rana Nashashibi: “Next time I go to Gaza, I won’t go as psychologist. I will go as a builder. What is needed is rebuilding. I’d rather build a house than offer counselling to individuals.”

From there it names three conditions for healing, and refuses to treat any of them as optional: safety and allyship — “Gazans also especially need the capacity to rebuild their own lives, human resources and infrastructures rather than being reduced to ‘recipients of aid’”; the right to agency, which requires “a transformation in the global narrative about Gaza from racist tropes that dehumanise Palestinians as ‘terrorists’, ‘human animals’, ‘human shields’ or ‘humanitarian cases’ to a people legitimately resisting injustice”; and acknowledgement, accountability and reparations, which “require perpetrators of violence to acknowledge the pain and suffering they have caused.” The paper’s position is that counselling delivered into a continuing catastrophe is not treatment. It is what a genuine response is measured against.

Why it matters

• Written by the Palestinian institutions that actually hold the caseload — Birzeit’s ICPH, the Palestinian Counseling Centre, GCMHP — and published in a mainstream medical journal, so it is citable in both registers at once.
• It states the intergenerational claim on the record, and grounds it by analogy to the documented experience of the children of Holocaust survivors, of Japanese Americans incarcerated during the Second World War, and of Cambodian genocide survivors in the United States.
• The Nashashibi line is the sentence to hand anyone who thinks the answer to Gaza is more therapists.

Key resources

• Unbearable suffering: mental health consequences of the October 2023 Israeli military assault on the Gaza Strip — full text
• Palestinians’ mental and physical Health — an interview with Rita Giacaman, Books & Ideas, 19 December 2023, in which she sets out “the invisible wounds inside” in her own words