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 games 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.