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| PERSPECTIVE/VIEWPOINT |
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| Year : 2022 | Volume
: 4
| Issue : 2 | Page : 112-120 |
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Continuous Traumatic Stress in Palestine: The Psychological Effects of the Occupation and Chronic Warfare on Palestinian Children
Iman Farajallah
Adjunct Professor at Graduate Theological Union, Berkeley Psychologist, Hyde Street Community Services, San Francisco, California, US
| Date of Submission | 29-Jun-2022 |
| Date of Decision | 29-Jun-2022 |
| Date of Acceptance | 30-Jun-2022 |
| Date of Web Publication | 22-Aug-2022 |
Correspondence Address:
Dr. Iman Farajallah
P.O. Box 3624, Santa Clara California, 95055
US
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wsp.wsp_26_22
For more than 70 years, the children of Palestine have experienced increasing levels of war trauma due to the ongoing conflicts with Israel. These children have been subjected to danger and violence to such an extent that it has created a societal underclass that has become the focus of research to determine the psychological impact of near-constant war. This article examines the growing body of literature devoted to analyzing how war and postwar trauma in children, specifically the children of Palestine, reveals a modern-day tragedy of epic proportions. The article presents the continuous traumatic stress in Palestine and the psychological effects of the occupation and chronic warfare on Palestinian children through the victims' war trauma experiences.
Keywords: Childhood trauma, occupation, Palestine, posttraumatic stress disorder
How to cite this article:
Farajallah I. Continuous Traumatic Stress in Palestine: The Psychological Effects of the Occupation and Chronic Warfare on Palestinian Children. World Soc Psychiatry 2022;4:112-20 |
How to cite this URL:
Farajallah I. Continuous Traumatic Stress in Palestine: The Psychological Effects of the Occupation and Chronic Warfare on Palestinian Children. World Soc Psychiatry [serial online] 2022 [cited 2023 May 31];4:112-20. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/2/112/354184 |
| Definition of Terms | |  |
Trauma
The word trauma originated from the Greek word for wound and was applied for physical injury before it became used for psychological injury by the end of the 19th century.[1] By definition, trauma is a psychological wound, and a traumatic event is a major stressor, which suddenly overwhelms a person, threatens their life or personal integrity, leaves no escape, and triggers accompanying horror that overwhelms the individual's ability to understand and cope with the situation.[2] The Diagnostic and Statistical Manual of Mental Disorders (DSM-5(3)) defines trauma as “exposure to actual or threatened death, serious injury, or sexual violence.”[3] Trauma is connected to the actual victim of threats, injury, or violence or witnesses of those threats, injuries, or violence.
Traumatic event
The DSM-5(3) definition of traumatic event requires all of the following diagnostic criteria: Exposure to actual or threatened death, serious injury, or sexual violence, in one or more of four ways: (a) directly experiencing the event; (b) witnessing, in person, the event occurring to others; (c) learning that such an event happened to a close family member or friend; and (d) experiencing repeated or extreme exposure to adverse details of the traumatic event(s).[3]
Lived experience
The term lived experience is used in phenomenological research to emphasize the importance of individual experiences of people as conscious human beings.[4] Lived experiences, as opposed to secondhand experiences, are experienced directly/.[5]
| Overview | | |
Children who survive man-made disasters such as war do not emerge unscathed and may pay a high price psychologically, emotionally, and/or behaviorally.[6] Studies of the psychological, emotional, and behavioral effects of war on children have compared those effects to child survivors of other forms of disaster that were not manmade, such as hurricanes, earthquakes, and floods, and found noted similarities in symptoms and coping mechanisms. Despite the overwhelming history of these effects on children of war, there is still much ongoing research into the full impact war has on children, including the long-lasting psychological effects.[7] Children who are exposed to war, ethnic cleansing, political oppression, concomitant interpersonal violence, and flight from their homes exhibit long-lasting impacts. It is not currently known whether the long-lasting impact of these events can be more likened to single-episode traumas (which are associated with a greater degree of recovery) or child maltreatment involving physical and sexual abuse (which is associated with more complex, diverse, and enduring outcomes).[8] All over the world, there is a direct parallel between children who have been exposed to war and victims of other overwhelming, disastrous life events.[9] Posttraumatic stress disorder (PTSD) studies indicate that children in all war-torn regions experience posttraumatic stress symptoms such as thoughts and sensory images that recur uncontrollably and certain behavior modifications that may not be obvious until they surface in a specific instance.[10],[11],[12] For example, the results of a child's exposure to war could lead to the child introducing a traumatic element to playtime, dreaming, storytelling, listening to music, and other activities. The results of a child's exposure to war may also manifest through avoidance of emotional expressions, such as a noted lack of interest in life and antisocial behavior; these have been a common concern since World War II.[9] There is a long history of descriptive reports of children's psychological reactions to wartime stress in many regions, including Cambodia, Afghanistan, South Africa, Bosnia-Herzegovina, Balkans, Kuwait, Palestine, Lebanon, and Iraq.[13],[14],[15]
After the Gulf War, 70% of Kuwaiti children reported moderate-to-severe posttraumatic stress reactions.[16] Depressed Bosnian adolescents who had moved to America during the Yugoslavian war were reported to exhibit PTSD and depression.[17] The National Institute of Mental Health (2015) defines psychological trauma as an emotionally painful, shocking, stressful, and sometimes life-threatening experience. The examples include natural disasters, physical or sexual abuse, and terrorism. Research must study the perceived impact of trauma from culture to culture to accurately assess its impact on children.[18] Specific coping mechanisms and protective factors appear to be independent of culture and societal structure. Long-term exposure to war and terrorism can undermine civil society, which can be very dangerous for children, as observed in Belfast, Mozambique, and many refugee camps in the late 20th century. As observed in massive trauma, when all the aspects of a child's ecology collapse (as seen in both war and natural disasters), the lives of children may be profoundly affected indirectly by the effects of the terror on the embedded systems in which they live.[19] When the order has disintegrated into chaos, there is the potential danger that children will affiliate with terrorists, form gangs, or emulate violent behavior if that is what they perceive will help to protect them. If civil society breaks down, which it often does in bombings and large-scale attacks such as those that decimated Aleppo in Syria, the disintegration of their world may be more of a threat to children's mental health in the long term than the war trauma itself.
| Experience of Palestinian Children in the Occupied Territories | | |
Palestinians have experienced wars generation after generation since 1917, when the British occupied Palestine. While Palestinians in the West Bank and Gaza have experienced many years of conflict and adversity, the situation in Gaza has worsened dramatically over the past decade. The Israeli air, sea, and land blockade on Gaza has stifled economic growth, entrenched, widespread poverty, and chronic food insecurity, and has caused long-term mental anguish for many Palestinians, in particular the children. The children of Palestine are subject to continued trauma due to the presence of war as an accepted fact of their lives.[9],[20],[21]Children in the Gaza Strip have experienced one war after another. They had no break: from the First Intifada (1987–1993), the Al-Aqsa Intifada (2000–2005), the Operation Cast Lead (December 2008 – January 2009), the Operation Pillar of Defense (November 2012), the Operation Protective Edge (July–August 2014), and finally to the most recent Israeli war on Gaza in May 2021, Operation Guardian of the Walls.[22]
The 2014 war was the most devastating round of hostilities since the beginning of the Israeli occupation in 1967.[23] The 50-day attack left more than 2,200 Palestinian civilians, including 551 children, killed. At least 142 Palestinian families with three or more members were killed in an Israeli attack. Over 11,200 Palestinian civilians, including 3,436 children, were injured, with 10% suffering a permanent disability.[24] Near 18,000 homes, 82 hospitals and clinics, and 259 schools in Gaza were destroyed or damaged during the 2014 conflict.[11] At the height of hostilities, 500,000 Palestinians, or 28% of the Gaza population, were displaced and 17,700 still remained displaced in 2018.[25]
Since Palestinians began mass protests around the Israel–Gaza borders on March 30, 2018, the humanitarian situation in Gaza deteriorated further. Between 2018 and 2019, almost 29,000 Palestinians have been injured since the protests began and more than 194 killed during the Gaza border protests, the Great March of Return. Women and children make up more than one in four of those injured and killed. Four hundred and forty-five girls and 5,334 boys were among the injured. Among those killed was 15-year-old Youssef al-Daya, who was shot by the Israeli army.[26]
Palestinians were shot by live ammunition, shrapnel, and tear gas canisters by the Israeli army.[27]
The Palestinian News and Information Agency Wafa have documented [Appendix 1] the killing of 2199 children at the hands of the Israeli occupation forces between 2000 and 2021. Furthermore, it recorded 28060 injuries among Palestinian children and 4280 arrests between the years 2008 and 2020 among Palestinian children by the Israeli forces. In response, the General Assembly of the United Nations deplored any excessive, disproportionate, or indiscriminate force by the Israeli military against Palestinian civilians.[28]
Many children in Gaza are living in constant fear that at any moment their lives might be upturned once again. Maysaa, who was severely injured along with her sister, lost her mother and brother, who were killed by the Israeli bombing in 2014. She expressed her fear of another war to come: “When I remember what happened, I become obsessed with it. When I see someone on the street, I ask them, do you think the war is over? They would reply, there is a war coming that is going to be worse than what we have already been through. I think to myself, are we better off than the ones who got killed? I then think, we can manage because we are old enough, but what about the children, what will happen to them? How are we going to help the little ones escape and protect them? As I relate that, I can hear my little sister screaming and crying.”[29]
Sure enough, in May 2021, the war hit again and Palestinian children once again had to experience the ugly face of war. The United Nations reported that during the 11-day war on Gaza from May 10, to 21, 260 Palestinians, including at least 129 civilians, of whom 66 were children were killed by the Israeli military attacks on the Gaza strip and 1,948 Palestinians, including 610 children were injured.[30]
| Psychological Impacts of War and Postwar Trauma on Palestinian Children | | |
War seriously erodes mental health in children and adults and can significantly change the lifestyle of an affected populace. The mental health of an entire nation is at risk in Palestine. In the past decade, several studies have reported high levels of mental health problems among children and adolescents, women, refugees, and prisoners in Palestine.[31] One study (Mousa and Madi, 2003) on Palestinian perceptions of their living conditions during the Second Intifada found that 46% of parents reported aggressive behavior among their children, 38% noted bad school results, 27% reported bedwetting, while 39% stated that their children suffered from nightmares. The study also claimed that more refugee (53%) than nonrefugee (41%) children behaved aggressively. Thirty-eight percent of the respondents said that shooting was the primary influence, 34% stated that it was violence on TV, 7% cited confinement at home, and 11% reported that it was the arrest and beating of relatives and neighbors. Seventy percent of nonrefugees and refugees indicated that they had not received any psychological support for the problems of their children.[32]
There are four ways to observe war that perpetuates the trauma: Watching someone else in that critical situation, a death threat to themselves, severe injury, and sexual harassment. People who experience any one of these categories can carry that memory for the rest of their lives every time they remember that traumatic event. In the Gaza Strip, children have experienced war trauma for more than three generations. Several studies suggest that, over time, the related effects of this trauma on the entire populace have contributed to a transformation of the Palestinian people into a traumatized nation.[33],[34],[35] Palestinian children have suffered greatly from the continued conflict that has consumed their territory for decades. Generations have grown up under the constant stress of war and its accompanying horrors. Research has increased, and studies document new atrocities that children suffer, while psychologists still measure and analyze the accumulated effects of earlier violence, death, and fear, daily on Palestinian children. The following content depicts a small portion of the attacks.
The research found that every child in Palestine had been exposed to at least three traumatic events.[33],[34],[35] The most prevalent types of trauma exposure for Palestinian children were as follows: 99% of children had suffered humiliation (either to themselves or a family member); 97% had been exposed to the sound of explosions/bombs; 85% had witnessed a martyr's funeral; and 84% had witnessed shelling by tanks, artillery, or military planes. Importantly, 41% of children suffer from PTSD. The United Nations Children's Fund (UNICEF) estimates that one million children live in Gaza Strip, and the fate of these children is determined by the area they live in, to witness death firsthand between wars. UNICEF also reported that about 250 thousand children in the Gaza strip are suffering from psychological problems and need help and support. According to the Norwegian Refugee Council, 11 Palestinian children, out of 60 children who died as a result of the recent Israeli airstrikes on Gaza in May 2021, were participating in a program of the Council, which aims to help them cope with the psychological effects of the tragedies they experienced during wars. The council described that the children died in their homes located in a densely populated area. A number of their relatives were killed and injured. Children's ages ranged from 5 to 15 years. The council reported that it works with 118 schools in the Gaza Strip, and it reaches more than 75 thousand students, through psychological and social intervention, within its program called “Better Learning Program.”[30]
In 2016, I conducted a research study titled “Children of War: Psychological Impacts of War and Postwar Trauma on the Palestinian Children in the Gaza Strip”[29] that provides evidence regarding how the ongoing war of Palestine has impacted the children of Gaza. The study shed light upon the children's narratives and their war trauma. While in Gaza, I interviewed children and their families to explore how the prolonged war has impacted the Palestinian children in the Gaza Strip mentally and physically.
Palestinian children in the Gaza Strip do not live typical lives. They observe their family members, neighbors, and friends being killed. Watching the murder of a close family member due to the Israeli bombing creates anger and frustration in children. They tend to be more aggressive and angrier. These children suffer from depression, anxiety, and continuous traumatic stress disorder. Save the children found that 95% of Palestinian children show symptoms of depression, hyperactivity, a preference for being alone, and aggression. They cannot even regularly attend school because of the bombing of school buildings and are prohibited from accessing essential school supplies. Even when they are able to go to school, their lives are extremely agonizing, with constant drones overhead preventing them from concentrating. Children become depressed when they return to school, and the friends who used to sit right next to them have been killed or have lost a body part due to severe injury. Some of the children interviewed stated that they had anger issues which they had to release by screaming. Some of them have nightmares, and some of them often wet their beds because of the nightmares. The fear of the war remains within them continuously. They are trapped with nowhere to go daily reliving their trauma to make matters worse.[29]
| Palestinian Children's Voices | | |
During the course of this research, I wanted to explore and elevate the voices of Gazan children who have survived the violence of war and who continue to suffer today, all while trying to understand and accept what happened to them. Wa'ad, a 16-year-old girl from Beit Lahia, suffers from depression and has become an introvert and socially withdrawn. She shared her thoughts and feelings about the war: “War is horrifying and terrible on every level. I found myself psychologically trapped and scared. I found myself with nowhere to be safe, not even my own home. Psychologically, I am tired of war. We are children, and there is no safe place for us. I am getting tired of hearing the word war. I am living in a place where I am not safe and not comfortable. All my dreams suddenly crumbled to ashes.”[29]
They were forced to flee their homes: “We escaped to the schools in Camp Jabalia, and we shared rooms with other families. We divided the rooms by a piece of cloth, where the men could sit outside and the women inside. For 24 h, you have to wear a headscarf. If I need to go to the bathroom, I have to go with a friend. Psychologically, I do not feel comfortable living there. This place is not suitable to be in, but you can say this is our destiny.”[29]
Another participant, Asmaa, has her own severe problems. She was badly wounded, along with her own children, but grieves for her lost family: “I cannot see with my eye anymore. My body is full of shells and bomb shrapnel. However, the most difficult thing is that my sister, my daughter, and my sister-in-law were killed. I saw my brother-in-law's kids on fire after the shelling in front of my eyes. I tried to come closer to them, the steam was coming out of their bodies, and all of them burned. I thank the Lord, they are better now. Their dad lost his limbs. Their mother was killed, and the children received treatment in Turkey.”[12]
Young Wael and his son Sharif were severely impacted physically and psychologically after the car their car was shelled by the Israeli army: “I feel a lot scared. Fear of the future. I will not remain what I was.” “Really sometimes, if I think about the future, I will have a nervous outburst at anyone in front of me. My nervousness and stress have increased. I easily get nervous and lonely and introverted, always worried and thinking about the future. I mean, if my friend called me out the door of the house, I get angry. I stayed outside the house for one, 2, or 3h because if I stay in the house, I will make problems with everyone.”[29]
Yazan is another child whose experience of being attacked has led to fear in his daily life. When he was asked if he gets afraid when he hears the sound of tanks and drones. He replied, “Yes.” When he was asked if he escapes from it or if he gets afraid of the F16s, and why he is afraid, he replied: “I flee because they will shoot me.[29]
The bombing and killing were widespread, leaving survivors with serious physical injuries, and often, not enough medical and financial resources to adequately treat the wounded, as in the cases of the following victims interviewed in this study. Asmaa, a Palestinian mother, lost 12 family members as she fled the bombing with her youngest daughter, unable to protect all of her other children. Asmaa stated: “I, my two children, and my husband were injured. My husband was injured in the eyes and head. I was injured in the eyes and my body. My back was open from the injury and I have bomb fragments in my entire body. My son was injured in the eyes. My daughter was injured in her chest. She has no nipple in her breast anymore (and began to reveal her daughter's breast) and shrapnel in her body and legs. I suffered a serious injury in my back and my eye. My entire body is full of shells and bomb shrapnel. Look and see, some of it still in my hand and my eye. My eye also has fragments in it and is injured from the inside. My entire body is full of shells and bomb shrapnel.[29]
Dr. Qadih, Ph. D. in Psychology, summarizes what Palestinians and their children face when the world fails to respond to the tragedy in Gaza: “The children of the war in 2014 have so far not received any help from the international community, or other social care, largely because the international community does not pay attention to the needs of the children, and the suffering of the Palestinian people. The international community seems to consider the impact to be temporary: They see physical trauma but not emotional scars. The international community needs to see the impact of suffering on people's emotions and passions, and their impact on future potential. The international community ignores the psychological needs and wounds of Palestinian children. I can assure you that 90%–95% of Palestinian children need comprehensive psychological care. Comprehensive psychological care does not come overnight, much less a short-term therapy lasting 3 to 6 months. Holistic psychological care requires long-term therapy lasting 3 to 5 years to restore a child's mental health. During my work with Palestinian children who visit our clinic, I have noticed that these children have behavioral, psychological, mental, and emotional disorders. With our limited resources, we try to provide as much psychological support as possible to our clients, but it inevitably falls short. The population in Gaza, young and old, need psychological support or treatment. Our limited resources with a few trained therapists are not enough to provide the specialized treatment and services needed for these children to heal.[29]
Dr. Owaida, who works for the World Health Organization in the Gaza Strip asked the question: “What are we required to do as psychologists in the Gaza Strip? Can we feel helpless and do nothing?” His answer is: “No. With the little resources we have, we will do our best but the world needs to understand that the solution to all of our suffering, including mental health, is for the occupation to end and for the wars to end…the solution is a political solution not only a psychological one. If I am treating a child for PTSD and he asks me, “can you prevent the death of my parents if a war hits?” My answer is: I simply cannot.”[29]
The drawings by Palestinian children participating in this study reflect the violence and trauma in their daily lives. Pictures of where they lived depicted bombed houses, tanks, drones, and warplanes, and children being shot by Israeli soldiers. One drawing shows a real house bombed with the little girl's pet cat inside it, and the little girl watches helplessly, unable to save it.
Palestinian children in the Gaza Strip showed symptoms of anxiety, depression, and PTSD. However, each child experienced different mental illnesses and their experiences with illnesses varied. Some of the children interviewed stated that they had anger issues which they had to release by screaming. Some of them have nightmares, and some of them often wet their beds because of the nightmares. The fear of the war remains within them continuously. This fear and anxiety are psychological problems resulting from exposure to war and conflict, and it is a feeling of distress resulting from fear of the coming danger. In this situation, it is war. This fear and anxiety can affect these children's ability to perform daily tasks such as going to school or even the restroom alone. Other symptoms such as muscle pain and sleep problems, difficulty concentrating, feeling tired after little effort, irritability, and anger occur among these children. Although these children share similar struggles, they experience vastly different mental illnesses from one another. Their own experiences with mental health are unique, and their trials in life and their mental health journey will not be comparable to others. Therefore, these children need comprehensive psychological care and specialized treatment, emphasizing the importance of treating every child's unique needs. Comprehensive psychological care does not come overnight, much less during a short-term therapy lasting 3 to 6 months. Holistic psychological care requires long-term treatment lasting 3 to 5 years to restore a child's mental health.[29] Palestinian children living in the war until now suffer from enormous psychological consequences due to the Israeli war. They are greatly affected by this protracted conflict's psychological and emotional trauma. The conflict between Palestinians and Israelis is still alive, painful, violent, and chronic, and there is no place to be a child under the Israeli bombs. With the recent war on Gaza in May 2021, it is evident that an insidious national tragedy is unfolding before our eyes, as Palestinian children are subjected to ongoing trauma due to the presence of war and violence in their lives. This serious psychological damage suffered by Palestinian children and the Palestinian people need concrete effort from the global community to combat the destruction of an entire culture and the accumulation of irreparable psychological damage resulting from the Israeli continued wars. It is essential to create programs that provide support, teach these children how to cope, and advocate for their psychological well-being. More importantly, eradicating both the sources of suffering and trauma and alleviating the suffering of Gazan children should be the highest priority. The vicious cycle of war and violence must end, and human dignity and rights must be respected.
| What Can We Do? | | |
It is essential to create programs that provide support, teach Gazan children how to cope, and advocate for their psychological well-being. More importantly, eradicating both the sources of suffering and trauma and alleviating the suffering of Gazan children should be the highest priority. The vicious cycle of war and violence must end, and human dignity and rights must be respected.
Citizens of the world have a responsibility: We cannot watch the murder of Palestinian children funded with military aid. We have the responsibility to ask our representatives to stop the aid, especially the sale of American weapons to Israel.
To help, we can also:
- Share news on social media, and talk to family and friends about what is happening in Gaza, Palestine, and the dire need for help in every aspect of life.
- Support research and development of mental health training programs in Gaza.
- Support programs that focus on trauma, emergency mental health care, mental and psychosocial services related to war trauma, and COVID-19.
As mental health professionals, we have a responsibility to support and advocate for the rights of Palestinians to have access to resources and mental health support. Furthermore, we need to demand that our Palestinian colleagues should be allowed to practice their profession without losing their lives or getting murdered like what happened to Dr. Mooein Ahmad al-Aloul, a 66-year-old psychiatric neurologist, who was killed in his home without any warning during the Israeli war on Gaza in May 2021.[36] The injustices taking place in Palestine for over 70 years should not make us normalize it or give up hope. We have to continue our support of the Palestinian cause until we bring change and no more people are murdered for no reason other than for being born Palestinian. We as human beings have a responsibility toward our fellow human beings. We have to stand up for justice and demand from our politicians that action must be taken now, to stop the daily bombing of Palestinians, end the murder of Palestinians, end the illegal settlements on Palestinian lands, end the confiscation of Palestinian homes, to respect Palestinian places of worship, to end the siege of the Gaza Strip, and to end the illegal occupation of Israel on Palestinian land. During my visit to the Gaza Strip for this research project, I observed that Palestinians are resilient people who do not give hope easily; love life and believe in their right to live in peace and dignity. As Palestinian men, women, and children told me, “Our only dream is to live in safety and peace.”[13]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Appendix
Appendix 1
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