Context The genocide in Gaza has created profound suffering for the Palestinians there who have endured its bombing, killing, infrastructure destruction, displacement and starvation. This suffering takes place within a continuum of violence: the wars on Gaza in 2008, 2012, 2014, 2021, and 2023; the blockade of goods; restrictions on freedom of movement, and displacement have left thousands of children, adults, and elders exposed to traumatic events--but this is only the recent history. Gaza endures systemic and event-based traumas that extend into the early nineteenth century and the displacement of the Nakba in 1948. Mental Health work has, for more than 40 years, sought to aid in catastrophe; continually revisiting assumptions about when and how mental health interventions are effective. The Palestine Trauma Center (PTC), a local mental health center in north-central Gaza, has been providing services to the community since 2007—these services continued through successive rounds of conflict, and through genocide (This work was supported in part by the Arts and Humanities Research Council and the Global Challenges Research Fund - AH/T008091/1). Aims This study explores and compares the benefits of two different mental health intervention programmes on a community in Gaza both before and during the genocide. The interventions under study are: Trauma Focused CBT (TF-CBT) and Focusing Therapy (FT), both of which have been locally adapted to the needs of the population over twenty years. The dual comparison yields findings on mental health in the context of genocide and its relationship to mental health in the context of the ongoing catastrophe that had preceded it. Methods Both interventions under study were developed based on a holistic and integrated approach to mental health aimed at empowering resilience among Palestinian patients with Post Traumatic Stress Disorder (PTSD) and subclinical PTSD. PTSD was assessed through pre- and post-assessments before and after individuals took part in either intervention. The PTSD assessment was made using a validated scale developed by Altawil [<CitationRef CitationID="CR7">7</CitationRef>], and PTSD was measured using the validated 33-item PTSD-SRII. Assessments were collected from a group of 827 participants, each referred to PTC for mental health assistance (self-referred or community referral), who engaged either the TF-CBT or FT. The number of participants who took part in both interventions before the genocide (BG) is 440, with a control group of 109. During the genocide (DG) interventions had a combined number of participants of 278. BG data was collected from April 2022 – September 2023, while DG data was collected between May 2024 and October 2025. The gap in data collection coincides with the start of the genocide. Although PTC staff and researchers agreed that the study should continue following the onset of the war in October 2023, participant recruitment and data collection could not begin immediately because the security situation in Gaza made it unsafe for both participants and the clinical research team. It was not clear in the early weeks and months how or when it might be safe or possible to continue data collection. Staff and clients were subjected to mass displacement, forced food insecurity, and the uncertainty of ongoing military operations. This severely restricted movement and prevented face-to-face recruitment and clinical assessments. Recruitment commenced on 1 May 2024, once staff were able to determine a safe approach to access participants in temporary shelters and other accessible locations. The majority of all participants across both time periods (87.5%) received 12 therapy sessions from either TF- CBT or FT. Control subjects (BG only) were evaluated over the same timescales but did not receive treatment during the study. Conditions meant there was no control group for the DG data. Interventions were assigned via screening by PTC staff, typically based on severity of symptoms and whether individuals had directly experienced a traumatic event. Those with broad spectrum experience of catastrophe in Gaza were assigned to FT, while those with specific experiences tended to be referred to TF-CBT. Therapies were delivered by trained clinicians with pre-/post-assessments and informed consent. Results Participants with low scores on PTSD assessment had better outcomes (reduced symptoms) when they participated in FT. Participants who were diagnosed with PTSD (had high scores on PTSD assessment), on the other hand, were more likely to have improved outcomes (reducing the severity of PTSD indicators) when they engaged with the TF-CBT intervention. This was the case both before and during the genocide. Results also found that the number of individuals referred for treatment who were evaluated for PTSD increased during the genocide. Of all participants evaluated before October 2023 (BG), 69.6% were assessed with PTSD, while 82% of participants evaluated during the genocide (DG) were assessed with PTSD. While interventions DG did largely continue to reduce PTSD symptoms, effectiveness was significantly reduced: 78.3% of participants who received either the TF-CBT or FT before the genocide (BG) had significantly reduced symptoms at their final evaluation, while only 52.5% of participants who received the interventions during the genocide (DG) had a significant reduction in symptoms at the final evaluation. While there was no control group for DG data, the BG control group did not show any improvements upon final evaluation, and in some cases symptoms increased. BG, group interventions were found to be more effective, and participants who received group treatment showed fewer PTSD symptoms and stronger improvements than those in individual treatment. DG, however, conditions were radically changed, and individual treatment was often the only option. So, while those who received individual treatment DG had stronger outcomes vs group interventions, this is likely due to the higher levels of vulnerability overall, as well as the isolation, increased exposure to danger, reduced social buffering and limited community safety that interventions were carried out within. Conclusion This study demonstrates that group interventions and community-focused methods are successful at significantly reducing PTSD indicators in contexts of ongoing violence and uncertainty, but that these methods lose effectiveness when community structure itself is damaged. Under conditions of genocide, community approaches in Gaza are less effective, at least when it comes to the reduction of PTSD indicators. Assessment of the context of these less effective interventions suggest that community mental health work might play a role in repairing social bonds, which in turn support the reduction of PTSD indicators. This study contributes important evidence to the global literature on trauma in genocide and war conditions.

The impact of genocide on PTSD treatment in Gaza: focusing therapy and trauma-focused CBT interventions

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2026年7月30日

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Mohamad A. S. Altawi,
Nora E. H. Parr,
Rob Foxcroft,
Patricia A. Omidian

摘要

Context

The genocide in Gaza has created profound suffering for the Palestinians there who have endured its bombing, killing, infrastructure destruction, displacement and starvation. This suffering takes place within a continuum of violence: the wars on Gaza in 2008, 2012, 2014, 2021, and 2023; the blockade of goods; restrictions on freedom of movement, and displacement have left thousands of children, adults, and elders exposed to traumatic events--but this is only the recent history. Gaza endures systemic and event-based traumas that extend into the early nineteenth century and the displacement of the Nakba in 1948. Mental Health work has, for more than 40 years, sought to aid in catastrophe; continually revisiting assumptions about when and how mental health interventions are effective. The Palestine Trauma Center (PTC), a local mental health center in north-central Gaza, has been providing services to the community since 2007—these services continued through successive rounds of conflict, and through genocide (This work was supported in part by the Arts and Humanities Research Council and the Global Challenges Research Fund - AH/T008091/1).

Aims

This study explores and compares the benefits of two different mental health intervention programmes on a community in Gaza both before and during the genocide. The interventions under study are: Trauma Focused CBT (TF-CBT) and Focusing Therapy (FT), both of which have been locally adapted to the needs of the population over twenty years. The dual comparison yields findings on mental health in the context of genocide and its relationship to mental health in the context of the ongoing catastrophe that had preceded it.

Methods

Both interventions under study were developed based on a holistic and integrated approach to mental health aimed at empowering resilience among Palestinian patients with Post Traumatic Stress Disorder (PTSD) and subclinical PTSD. PTSD was assessed through pre- and post-assessments before and after individuals took part in either intervention. The PTSD assessment was made using a validated scale developed by Altawil [7], and PTSD was measured using the validated 33-item PTSD-SRII. Assessments were collected from a group of 827 participants, each referred to PTC for mental health assistance (self-referred or community referral), who engaged either the TF-CBT or FT. The number of participants who took part in both interventions before the genocide (BG) is 440, with a control group of 109. During the genocide (DG) interventions had a combined number of participants of 278. BG data was collected from April 2022 – September 2023, while DG data was collected between May 2024 and October 2025. The gap in data collection coincides with the start of the genocide. Although PTC staff and researchers agreed that the study should continue following the onset of the war in October 2023, participant recruitment and data collection could not begin immediately because the security situation in Gaza made it unsafe for both participants and the clinical research team. It was not clear in the early weeks and months how or when it might be safe or possible to continue data collection. Staff and clients were subjected to mass displacement, forced food insecurity, and the uncertainty of ongoing military operations. This severely restricted movement and prevented face-to-face recruitment and clinical assessments. Recruitment commenced on 1 May 2024, once staff were able to determine a safe approach to access participants in temporary shelters and other accessible locations.

The majority of all participants across both time periods (87.5%) received 12 therapy sessions from either TF- CBT or FT. Control subjects (BG only) were evaluated over the same timescales but did not receive treatment during the study. Conditions meant there was no control group for the DG data. Interventions were assigned via screening by PTC staff, typically based on severity of symptoms and whether individuals had directly experienced a traumatic event. Those with broad spectrum experience of catastrophe in Gaza were assigned to FT, while those with specific experiences tended to be referred to TF-CBT. Therapies were delivered by trained clinicians with pre-/post-assessments and informed consent.

Results

Participants with low scores on PTSD assessment had better outcomes (reduced symptoms) when they participated in FT. Participants who were diagnosed with PTSD (had high scores on PTSD assessment), on the other hand, were more likely to have improved outcomes (reducing the severity of PTSD indicators) when they engaged with the TF-CBT intervention. This was the case both before and during the genocide. Results also found that the number of individuals referred for treatment who were evaluated for PTSD increased during the genocide. Of all participants evaluated before October 2023 (BG), 69.6% were assessed with PTSD, while 82% of participants evaluated during the genocide (DG) were assessed with PTSD. While interventions DG did largely continue to reduce PTSD symptoms, effectiveness was significantly reduced: 78.3% of participants who received either the TF-CBT or FT before the genocide (BG) had significantly reduced symptoms at their final evaluation, while only 52.5% of participants who received the interventions during the genocide (DG) had a significant reduction in symptoms at the final evaluation. While there was no control group for DG data, the BG control group did not show any improvements upon final evaluation, and in some cases symptoms increased.

BG, group interventions were found to be more effective, and participants who received group treatment showed fewer PTSD symptoms and stronger improvements than those in individual treatment. DG, however, conditions were radically changed, and individual treatment was often the only option. So, while those who received individual treatment DG had stronger outcomes vs group interventions, this is likely due to the higher levels of vulnerability overall, as well as the isolation, increased exposure to danger, reduced social buffering and limited community safety that interventions were carried out within.

Conclusion

This study demonstrates that group interventions and community-focused methods are successful at significantly reducing PTSD indicators in contexts of ongoing violence and uncertainty, but that these methods lose effectiveness when community structure itself is damaged. Under conditions of genocide, community approaches in Gaza are less effective, at least when it comes to the reduction of PTSD indicators. Assessment of the context of these less effective interventions suggest that community mental health work might play a role in repairing social bonds, which in turn support the reduction of PTSD indicators. This study contributes important evidence to the global literature on trauma in genocide and war conditions.