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Children under four exposed to violence inside the war zones of Israel and Gaza have a greater risk of suffering long-lasting psychological damage, medics have said.
Healthcare workers dealing with battlefield injuries, as well as families sheltering from rocket attacks with young children, are also most likely to need psychological support.
Dr Maya Bizri, a clinical psychiatrist and global mental health consultant in disaster psychiatry in Beirut, said the psychological risks to people exposed to violence were two-fold, especially in children under four.
“There is a risk of post-traumatic stress disorder (PTSD), even if there is only indirect exposure to trauma,” she told The National.
“This is especially true for children who have had history of adverse childhood events, regardless of the type of previous trauma, such as neglect, bullying or physical violence.
“There are also non-war related studies that look at the risks of just social media violence – a topic that has been controversial for years.”
Millions of people have been exposed to horrific images by internet video.
Dr Bizri said that exposure to violent media can cause aggressive thoughts and behaviour, angry feelings, physiological arousal, desensitisation to violence and a view of the world or other people as hostile.
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“It also decreases prosocial behaviour, such as helping others and empathy,” she said. “Again, this is not necessarily pertaining to war itself.”
More than 1,500 people in Gaza have been killed in six days of Israeli strikes, while Saturday's Hamas attack on Israeli settlements killed about 1,300 people. The majority of the dead on both sides were civilians.
Children in Israel have been told to delete social media apps to shelter from videos showing Israeli residents being shot at point-blank range, the massacre of revellers at a music festival and the abduction of young children and the elderly.
Home petrol bombed
Sarah Tuttle-Singer, a 42-year-old mother of three and author from California, has been living in Israel since 2010, and in Jerusalem since 2018.
Since the outbreak of violence, her home has been petrol bombed.
“There was no major damage or injuries, but the psychological impact is pretty tremendous,” she said.
“Most of the apartments don't have safe rooms, our building doesn't seem to have a safe place to go.
“We've always felt like Jerusalem was fairly safe because there are holy sites here, but not any more.”
Her family lives in a flat in southern Jerusalem, close to an access road that leads into the desert and the West Bank.
Schools have been shut across Israel since the first Hamas attacks on Saturday.
Ms Tuttle-Singer is worried about the conflict's impact on her three children – a baby boy, her 14-year-old son and daughter, who is 15.
“The impact is severe, but we don't quite understand it yet because we’re still living this,” said Ms Tuttle-Singer.
“I still have PTSD from the 2014 war. Every Israeli and also every Palestinian has some form of PTSD I’m sure.
“When things settle down, it's probably going to hit my children in a very real and painful way.
“Luckily here in Israel, online psychological services are offering free treatments.
“Therapists are working at a discounted rate in order to help kids and parents cope.”
Mental health support
The kind of mental health support framework in place across Israel is far from a priority in Gaza, where two million people are battling for survival, without power or running water.
An evacuation of north Gaza ahead of an impending ground invasion from Israeli troops will compound the trauma of many who have been under intense shelling for days, with more than 6,000 bombs already unleashed.
Dr Marc Sinclair, a Dubai-based specialist paediatric orthopaedic surgeon, was among six volunteer medics working for the Palestine Children’s Relief Fund who were trapped inside Gaza during shelling in May.
He now fears for the mental welfare of children forced to flee their homes, and medics inside the enclave.
“I've been going there for 12 years, so I have a lot of sympathy with the doctors working there,” said Dr Sinclair.
“These children cannot go anywhere and they see this every one to two years, so the psychology for them is huge.
“More than half the children in Gaza are clinically depressed, but I think the number is actually more like two-thirds.
“Children self-harm because of the stress, and it's horribly upsetting.”
Without the luxury of widespread hospitals and clinics, psychological support for those in need will be in short supply, Dr Sinclair said.
“Psychological counselling is a specialty that requires repeat visits, a process that needs time,” said Dr Sinclair.
“If we're going to have volunteer psychologists that are available remotely on Zoom, where you can book appointments and talk to them, maybe that's a good thing.
“The need is there, there's no question.”
Frontline carers at risk
Mental pressures are also taking a toll on frontline healthcare professionals.
Despite being the first line of care for those with battlefield injuries, medics at Sheba Medical Centre in Tel Aviv, Israel's largest hospital, have struggled to come to terms with the unfolding carnage.
Yoel Har-Even is director of Sheba Global at the centre, where more than 200 people have been treated since the latest conflict began.
“The most senior staff at our hospital are ready to see and treat such events – but we are all human beings,” he told The National.
“At the end of the shift, when you have a few minutes to think about what has happened, you get flashbacks on the way home or even when you are trying to get some sleep.”
The hospital has support services to help, including social workers working with staff and senior physicians who are debriefed every morning.
“You develop a resilience while you are working in such an area, in such a country,” said Mr Har-Even, who served in the army medical corps for 28 years.
“I heard one of the doctors say to me, as tough as it is for him to deal with, working on wounded patients is actually therapy for him.
“He's saving a life and he's putting people back together again. That makes him feel good.
“If he had to think about everything he had to deal with, it would destroy him.”
