Beyond the battlefield: The mental health fallout of military conflict

The connection between mental health and warfare is profound, affecting those directly involved in conflict zones and those observing from afar. In the case of the Israeli bombing of Gaza, where innocent civilians are often caught in the crossfire, the impact on mental health can be devastating.

A 2022 report issued by Save the Children, a London-based international non-governmental organisation that promotes children’s rights, reveals troubling insights into the effects of war and displacement on Palestinian children. The study, titled “Trapped: The impact of 15 years of blockade on the mental health of Gaza’s children,” details the detrimental effects of the blockade imposed on the Gaza Strip since June 2007, and finds that the psychosocial well-being of children and their caregivers in Gaza has declined dramatically. A lifting of the blockade would end some of the stress on these children, but resources would still be required to build back their ability to cope with the long-term effects of the trauma.

Diagnosis: Bleak

A paper in the World Psychiatry journal called “Mental health consequences of war: a brief review of research findings” notes that “Wars have had an important part in psychiatric history in a number of ways. It was the psychological impact of the world wars in the form of shell shock that supported the effectiveness of psychological interventions during the first half of the 20th century.”

Shell shock has come to be known as post-traumatic stress disorder (PTSD), and is just one of the psychological disorders that affects people living in a conflict areas. In Gaza, for example, people are exposed to the wailing of sirens and unexpected explosions. At any minute, families might have to flee where they are living. They may witness violence or have their homes destroyed. This constant fight-or-flight situation causes elevated levels of stress hormones such as cortisol, which have deletrious effects on decision-making. Anxiety, depression, and chronic stress are common diagnoses amongst those exposed to war.

Death is one of the most traumatic events a person goes through, and the war in Gaza has brought new deaths daily. The collective trauma of losing loved ones and witnessing widespread destruction can lead to complicated grief and emotional distress. Furthermore, the ongoing conflict perpetuates a cycle of trauma, as each new round of violence reignites past traumas and deepens existing wounds. Individuals who survive warfare may experience survivor’s guilt, which can lead to feelings of worthlessness, shame, and emotional distress.

Even those watching the events of war abroad can experience psychological distress. The constant stream of news and images of suffering and destruction can lead to a phenomenon known as “secondary traumatic stress” or “compassion fatigue”. This condition mirrors symptoms of PTSD and can affect anyone who becomes deeply empathetic towards the victims of these conflicts. The sense of helplessness and frustration at not being able to provide direct assistance or influence peaceful resolutions can further compound these feelings.

“The act of witnessing can be a heavy one…but it can take its toll and lead to burnout if it’s not managed correctly,” says Dr Hala Alyan, a Palestinian-American clinical psychologist based in New York City who specialises in trauma. “Especially in this case, when people feel tremendously helpless, that witnessing is absolutely laden with trauma.”

For some, this empathetic distress can lead to activism or charitable work, as a means of attempting to make a positive impact. Without proper emotional support, however, even these well-meaning efforts can become sources of stress and burnout.

A war like no other: The unique mental health concerns of Gazans

The blockade and restricted movement out of Gaza create a unique set of stressors. The area is one of the most densely populated areas in the world, and these close quarters, especially in a time of constant bombardment, can make citizens feel trapped. A significant portion of Gaza’ s population is under 18. Young people by definition haven’t developed emotionally into adults, and many don’t have the resilience to cope with violent conflict. This could have long-term effects after the war, especially if the attacks go on longer.

The Syrian Civil War between 2012-2017, the 1992-1995 Bosnian War, and the Rwandan genocide in 1995 share similarities with Gaza today. In all of these conflicts, homes, schools and hospitals were bombed. This loss of civilian infrastructure causes a disruption in the daily life of citizens, and the longer the normal routine is broken the more difficult it becomes to start anew. War also causes displacement, and thus breaks up communities, which are key to psychological stability.

The long-term mental health consequences of war depend on individual experiences. The intensity, longevity, and death toll of the conflict all factor in. A 2019 study on the Bosnian war found that “the cumulative effect of war trauma on mental distress persisted more than a decade after war and displacement.” Victoria Uwonkunda, a survivor of the Rwandan genocide, described her “invisible disease” to the BBC in 2021. “It triggers panic attacks that can come at any time and which leave me struggling to breathe. I am usually covered in a thin layer of cold sweat when they subside, as I fight to get back to my ‘normal’ self.”

The current campaign is not the first time many Gazans have been subjected to war. Some who went through such events as the Great March of Return or the 2008-2009 or 2014 Gaza Wars, developed coping strategies, but many with PTSD will be triggered by the renewal of violence.

When the healers need healing

The ongoing war in Gaza has pushed the healthcare system to the brink of collapse. Hospitals have been attacked and medical supplies blockaded at the very time when demand for mental health services is at its highest.

Doctors and other health care professionals and humanitarian workers work in dangerous conditions, in a system that is underfunded and overstretched. The current conflict has only intensified these needs, with mental health providers, who are also part of the affected society, facing the dual challenge of coping with their own traumas while trying to support others.

Médecins du Monde, also know as Doctors of the World, is an international humanitarian organisation dedicated to providing medical care to vulnerable populations. The organisation has warned that Palestinians have a high level of mental health issues, with a significant portion of the population, especially children, in dire need of Mental Health and Psychosocial Support services.

The establishment of a ceasefire would create an environment where mental health professionals can operate more freely and safely, allowing for the expansion of services and outreach to those in dire need. Experiences from post-conflict regions, such as the Balkans and Rwanda, emphasise the importance of rapidly deploying mental health and psychosocial support services following the cessation of hostilities. These services must be culturally sensitive, trauma-informed, and accessible to all segments of the population, particularly children who have been disproportionately affected.

Dr Kristian Alexander is a Senior Fellow and the Director of International Security & Terrorism Program at TRENDS Research & Advisory (Dubai)

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