How displacement impacts mental health in Gaza

Since breaking the ceasefire on March 18, Israeli forces have issued 31 displacement orders, which are often unpredictable and delivered with short notice through leaflets, social media posts, or phone calls informing recipients of an imminent attack. This state of constant displacement is taking a toll on Palestinians’ mental and physical health. 

Recently, we spoke with Doctors Without Borders/Médecins Sans Frontières (MSF) mental health supervisor Iman Abu Shawish about the psychological impact of displacement. Here’s what she said. 

What is the psychological impact of the displacement orders issued by Israeli forces in Gaza?

Displacement in itself is a loss. It's a loss for people who are important in your life,  just like when you lose a job, a place, or a life routine.

The psychological impact mirrors the five stages of grief: denial, anger, bargaining, depression, and acceptance. There are a lot of individual differences depending on the personality, past experiences, support system, and ability to cope. Denial, for example, can last for an hour or years depending on the person.  

Suppose that you are in one of these stages. Even if you are in the bargaining or denial stage, it may seem to people that you are stable, because they don't see any reaction from you. But deep inside, there are a million processes in the brain. It can be chaos as you are processing what happened.

We find different reactions. People can get very aggressive, verbally or physically, and there are people on the other extreme, completely isolated; they don't have relationships, they don't like to hang out, they withdraw from everything, they feel depressed. But here's the cruel reality: Just when someone reaches acceptance, another evacuation order comes.

Anxiety may occur in all forms, including panic attacks or panic disorder. There are also traumatic reactions, which we call post-traumatic stress disorder (PTSD) or acute stress disorder which includes many things, for example dissociation. One nurse described that when she goes to work and comes back, she keeps looking at her hands asking herself if she is real or not. A child once looked at me and told me, “I think I am dead but if you can hear me, maybe I am alive.”

Our brain does not differentiate between reality and imagination. No matter if you are in a house or in a tent, your brain thinks that anxiety and anticipation are real. The person has to deal with what happened even if it was already expected. Then depression sets in, and when another evacuation happens you start again a cycle that never ends.  

Acute stress reactions include images or detailed memories from previous evacuation orders and become intrusive. The resulting stress and anxiety can provoke reactions in the body, for example muscular and abdominal pain, shaking, and fatigue. It affects children—the way they play, their emotions—and we see cases of children building tents as a game. The games recreate evacuations; those are their flashbacks revealed through their only form of expression.  

People who went through displacement orders at least once are forced to relive it again and again. So even if their current living conditions are bad—living in tents, barely making ends meet—evacuation means restarting from zero. Humans crave stability, but evacuation means chaos, change, loss. For Gazans, that has been the cruel reality for more than 19 months now.  

We hear accounts of people deciding to stay where they are despite displacement orders. How do they cope with the situation?

One person I treated was hit in her family house; she was the only survivor. Later she was killed too. Why didn’t she evacuate?  

People often blame themselves. ‘Why did I stay?’ ‘Why didn't I leave?’ This guilt isn't rational because they had no other safe options. But the brain keeps searching for explanations, creating false responsibility. For example, one woman hated her brother because he didn't act with 'intuition' before Israeli forces bombed her home, killing her parents.

Survivor’s guilt has nothing to do with the evacuations, but comes from the context. Some people think ‘why did I not die with them?’ It is difficult to make a person feel positive no matter how hard you try. The support system is falling apart because people who support you live in the same conditions.  

Anxiety, depression, negative emotional state, inability to live positive emotions—we do not have time to cope in the right way, because our brains are not free to think, or to assess situations in the right way. We think about other things—how to get food, water, bread. And we often do not have a support system, so it is complicated in all aspects.  

Displacement orders are often unpredictable and delivered with short notice. Do you consider the way these orders are issued to be a form of psychological punishment?  

The cruelty is not only in the evacuation orders themselves, but also in how they are phrased. These aren't straightforward military orders; they are psychological traps. The Israeli army doesn't just tell people to leave; they twist the very symbols that once gave Palestinians comfort. Quranic verses about 'divine punishment' printed on evacuation flyers. Classical Arabic poetry about exile used in social media warnings. Even their spokesperson's tweets become sudden death notices, no clear timeframe, just a vague threat broadcast to millions already traumatized. 

After 19 months of war in Gaza, do you see any hope for people's mental health in this context?  

There is an important term in psychology which is PTG, post-traumatic growth, and I have seen this a lot. There are colleagues that have adopted a positive change in their way of thinking, in their behavior after the trauma. As people, we learn to deal with trauma, meaning we say,  “okay, there was displacement, then ceasefire, okay the house got bombed and we got out of it.”

We adopt new personality traits, a different way of thinking, different behavior.  

I was wondering how people were able to continue and function. How did a nurse who lost all her family keep coming to work, how does she not give up? Of course they are triggered by the experiences, but the growth of this nurse made her able to deal with it, because she came up with a new meaning. Every time memories come up, a new meaning comes up as well. And this is an important component of our resilience.

Many factors need to be put together: personality traits, past experiences with childhood. Humans are the most difficult things to predict, and that's why psychology is considered one of the most difficult sciences on earth.