The line outside Dr. Bahzad al-Akhras’s clinic starts to assemble before sunrise, a ripple of bodies in the half-light standing barefoot or in frayed sandals, waiting for a turn at what now passes for care. His clinic is wherever it needs to be: in a corner at a shelter compound, on the move during a walk around the yard, or behind the makeshift screen of a bedsheet pulled between two poles, if the wind allows. Often, Akhras sees patients in a tented space, tucked among hundreds of other such tents in the dense sprawl of Al-Mawasi, in the southern end of the Gaza Strip.
Akhras, a child and adolescent psychiatrist, lost his home to an Israeli strike, in early 2024. He and his family have been displaced multiple times, living in tents where the canvas sweats from too many bodies pressed into too little space. He no longer sits in a white-walled office or wears a badge. But he continues to work, seeing some fifty patients a day, most of them children. One of his regular patients is a young girl, no older than fourteen, who survived a strike that killed her entire family. She woke up in an I.C.U., alone, unable to understand where everyone had gone. Now she sits in front of Akhras in silence, until she asks, again and again, if he can bring them back. He has no answer, only a pencil stub and a coloring book, which he hopes she can use to express and process her emotions.
With barely functioning systems and almost no resources, practitioners such as Akhras rely on the few tools they have left: psychosocial support, cognitive behavioral therapy (C.B.T.), and improvised coping strategies. They teach breathing exercises, emotional regulation, and techniques to manage intrusive thoughts. When possible, they coördinate with overwhelmed medical staff to access limited psychotropic medication for patients with severe depression, psychosis, or suicidal ideation. But, as Akhras told me, most professional support has shrunk to voice notes between colleagues that ask just one question: “Are you still alive?”
Medical workers can sometimes suffer from secondary traumatic stress—a kind of emotional injury absorbed from witnessing the pain of others. But there is nothing secondary about the trauma experienced by Gaza’s mental-health-care specialists. “We are struggling, mourning, surviving, and working, all at once,” Akhras told me. “There’s no space for my emotions. They sit in my chest like a stone.” When he’s not with patients, he’s searching for water, or trying to calm his own parents. There’s no time to write notes or to process, no space even to collapse. “We try to hold others so they don’t fall,” he said. But he’s falling, too, just more quietly.
In Gaza, therapy has become a language of holding on. More than sixty thousand people have been killed in twenty-one months. The hidden toll, however, spans entire flattened neighborhoods and erased communities. Those who remain face widespread famine, collapsing access to health care, and the daily terrors of survival.
After three hundred days of war, the UNRWA issued an analysis describing Gaza’s trauma as “chronic and unrelenting”—a collective embodiment of continuous traumatic stress disorder (C.T.S.D.), a condition that stems from living under relentless trauma. Unlike post-traumatic stress disorder, which sets in after a difficult experience, C.T.S.D. is what occurs when there is no end in sight. Gazans have adapted to chronic danger, living in a state of hypervigilance, emotional numbness, and dissociation amid the slow erasure of any imagined future.
The effect on children has been especially catastrophic. By 2024, UNICEF estimated that almost all of Gaza’s 1.2 million children require urgent mental-health and psychosocial support. Not a single child has been untouched by the war. Many aren’t sleeping, or they wake screaming throughout the night, clinging to their companions in terror. A number of children have developed speech problems. Some reënact bombings with stones, play a game called “air strike,” or act out death.
By February, 2024, UNICEF estimated that at least seventeen thousand children were unaccompanied or had been separated from their families. By April of that year, the Gaza health ministry had documented more than twelve thousand wounded children, a number that, in 2025, has increased to fifty thousand killed or injured, according to a report by UNICEF. Alone, displaced, and traumatized, the children who are still alive are extremely psychologically vulnerable. Even before this most recent war, Gaza’s children were already showing signs of strain: a 2022 Save the Children survey found that eighty-four per cent felt fear and seventy-eight per cent lived with grief. In November, 2024, a report by the Community Training Center for Crisis Management found that ninety-six per cent of children living through this war feel that their death is imminent, and nearly half said that they want to die.
The first time my three-and-a-half-year-old son, Rafik, asked me “Are we going to die today?” was in December of 2023, roughly two months after the war began. We were lying in a recovery bed, still shaking from the blast that had buried us beneath the concrete roof of our house, in Gaza City. My entire family had passed out before we were found bleeding. Rafik was curled up on the ground, close enough that I could see him, but too far for me to reach out and hold him. After we were pulled from the rubble, I remember thinking, This is the moment that rewires a child forever. I’ve been watching that shift occur in front of me ever since.
Nour Jarada, a mental-health manager in Gaza, sees this rewiring on a daily basis. She works inside of medical tents that have no sound insulation, each one containing folding beds that separate trauma from trauma. The patients arrive on foot—some having walked for miles, many led in by family members who didn’t know what else to do. “Some don’t speak,” she told me. “They stare, sometimes scream. Most cry for hours, unblinkingly.” Children have asked Jarada if they could go back to school, as if normal were still hiding somewhere nearby.
Jarada told me about a fourteen-year-old boy who, in early 2024, had stepped out to buy something from the market. While he was gone, an air strike levelled his home, killing nearly everyone in his family, except his younger brother. The two are now completely alone. “I wish I had died with them,” the older boy said to Jarada.
Jarada used to work in a clinic that had a modest therapy room: shelves of toys, a rug, and illustrated books. It was a space for listening to the inner world of children too young to carry this much pain. Now, much like Akhras, she relies on things like salvaged toys and colored pencils to comfort young patients. “I tell them it’s O.K. to cry,” she said. “But I whisper it because I don’t want to break, too.”
For Akhras and Jarada, traditional frameworks of therapy no longer suffice in a place overwhelmed by ceaseless suffering. Several months before the war began, they had travelled to the U.S. to complete an observership with the International Visitor Leadership Program, a government initiative that brings together professionals from around the world to foster collaboration and exchange knowledge. They came back to Gaza in June, 2023, equipped with new ideas, only to soon meet a reality that has continued to defy everything that they had learned.
It was just days into the war that Gaza’s mental-health infrastructure began to collapse. On November 5, 2023, a psychiatric hospital in the Strip stopped functioning, after reportedly sustaining damage from an attack. Community mental-health clinics, meanwhile, have either shut down or been relocated owing to insecurity or lack of staff. As a result, nearly half a million individuals struggling with mental-health conditions have lost access to essential care.
Humanitarian actors have tried to fill the gap, but the scale of the crisis is overwhelming. In late 2024, some eight hundred thousand people across Gaza and the West Bank had received some form of mental-health or psychosocial support, according to the World Health Organization. This assistance has ranged from child-friendly spaces and group activities provided by UNICEF to emergency psychosocial interventions from N.G.O.s, such as American Near East Refugee Aid, which has set up structured activities for more than a thousand displaced children in shelters and camps. But these forms of support are largely short-term and basic—designed for psychological stabilization rather than long-term healing. In the context of mass displacement and prolonged trauma, there is still a critical need for sustained, intensive care. The UNRWA reported in August, 2024, that, of an estimated 1.3 million people displaced in Gaza, only about ten thousand had received counselling support, and some seven thousand had received specialized treatment, including cases for psychiatric disorders.
Jarada told me about a mother of five who had mild depression prior to the war. Then came displacement, the death of her loved ones, the loss of her home, and hunger in the tents. She became suicidal. Jarada built a care plan from scratch: cognitive-behavioral therapy, breath work, antidepressants, emotional regulation, and practical survival routines. “This is what war does,” Jarada said. “It turns manageable illness into a life-threatening emergency.”
Before the war, Arwa al-Sakafi, a child psychologist, medical trainer, therapist, teacher, and mother, worked at a private clinic in Gaza, guiding children through emotional wounds, training therapists to build psychological safety, and running workshops on trauma recovery. “My workshop became a morgue,” she told me. In the first weeks of attacks, she found herself in U.N. tents, school corridors, and shelters, treating amputees and children who had been pulled from rubble while their siblings and parents remained under it. Her own family was displaced three times: from Gaza City to Deir al-Balah, then Rafah, then Al-Zawaida.
Sakafi is one of the rare psychiatrists who works in a small center that is still standing. She and Ghadeer el-Shurafa, a clinical psychologist who specializes in trauma-focussed C.B.T. and narrative therapy, are part of a dwindling team at an organization called HEAL Palestine. Shurafa tracks trauma across camps and shelters, and has lost count of how many teen-agers she’s treated for suicidal thoughts. Her clipboard has grown heavy. “Sometimes I feel like I’m just watching my own pain walk through me while I stay silent,” she said. “But therapy, at its best, becomes a place to breathe—for them and sometimes for me, too.”
In one session, Shurafa met a group of girls who had been displaced. They’d seen artillery, severed limbs, and fire. They entered the room like mirrors of one another: same posture and hollow stare. When she asked them to choose a color for their feelings, most picked black, or dark purple. They drew tanks, mothers, and blood.
“The trauma was synchronized,” Shurafa told me. “It’s not something they can leave behind while they’re still living it, but we can try to regulate it.” As she spoke to me, her tone was steady, almost hushed. “In war,” she said, “silence is honest. My presence, my gaze, my quiet voice—sometimes that’s the entire therapy.” Often, sessions are interrupted by a nearby strike. The room shakes, the door flies open, and she and her patients run. But, even then, Shurafa tries to leave her patients with something. A phrase. A touch. “We’ll continue,” she tells them. “We won’t abandon you.” Both Sakafi and Shurafa have enough reasons to stop showing up. But they don’t. They lean on each other. On prayer. On glances passed between colleagues who are too exhausted for full conversations. Sakafi said they remind each other to keep going, even when their bodies want to quit.
I reported on this war from the ground for months, writing about destruction and starvation while living through it. I’ve written about the deaths of others while unsure if I would make it through the night. I left Gaza on April 7, 2024, and, though I’m no longer worried about my own immediate safety, I live in constant fear for the people I love who remain there. “In the heart of destruction,” Jarada said, “we hold each other, sometimes just long enough to make it through the next hour.” I’ve learned to do the same, both in Gaza and from afar.
There’s no psychological manual for this, no diagnosis that makes it livable. There is a vocabulary of collapse that one learns by living through it. It begins with the grief loop: mourning relatives, then neighbors, then co-workers, then children whose names we never knew. I lost friends, then family, then my block, then colleagues I shared hunger and dispatches with—journalists still reporting as the sky falls. The mourning rotates endlessly.
Then comes the vertigo: Why not me? Why was I pulled from the rubble with my child alive in my arms while another man lost all five of his? Those questions sit in the throat like dust. Fear follows, shapeless and untimed, not triggered by the next strike but by a slammed door, a bird landing too hard, a cough that echoes like a crack of fire. My body folds the way it did that day, under that roof, before I knew we’d make it out. Disembodiment sets in. The mental-health professionals I spoke with described, among their patients, children who no longer flinch, toddlers who don’t respond to their names, others who have stopped crying all together—survivors still walking but no longer present. Therapist fatigue follows, an invisible kind of breakdown. Shurafa told me she sometimes watches her pain speak through someone else.
Akhras put it simply: “People say they don’t feel anything anymore. They can’t cry. They can’t love.” No one talks about recovery, not even those of us who made it out. The mind is just trying to stay in the body. Some mornings, I wake up and reach for my own breath, half expecting not to find it. But then I do—and that, for now, has to be enough. ♦
