In the Shadow of the Israeli-Palestinian Conflict: Reflections on Cultural Safety and Clinical Care for Children and Adolescents in Quebec (Canada) in Polarized Times

Abstract

The ongoing Israel-Palestine conflict has significant consequences for children, youth and families from diverse communities in North America. In a time of widening social polarization, many children and youth are implicated in reiterations of the conflict at home, at school or in their neighborhoods. This divisive context has numerous indirect and direct clinical consequences requiring clinicians’ awareness, attunement, and skillful response. Building on clinical experiences in Quebec (Canada), this paper questions the cultural safety of clinical interventions at three levels. First, the conflict can alter the therapeutic alliance in unspoken ways, requiring ongoing attention to cultural and contextual securitization. Second, because of its potentially traumatic impact, the conflict can influence symptom presentation in subtle or overt ways. Third, the internalization of the conflict can prompt forms of challenging acting-out, potentially eliciting stigmatizing clinical or social responses. Overall, preserving cultural safety in this context requires favouring a systemic assessment of the patient and their lived experiences, considering simultaneously the family, school and community context. Minimizing silence and avoidance by addressing the possible distress and divisions-or indeed outright divergences-within clinical and school teams may foster a respectful and safe enough environment, in spite of the differences in meaning within and across heterogeneous communities.

Plain Language Summary

The ongoing Israel-Palestine conflict has significant consequences for children, youth and families from diverse communities in North America. In a time of widening social polarization, children and youth are implicated in reiterations of the conflict at home, at school or in their neighborhoods. This divisive context has numerous indirect and direct clinical consequences requiring clinicians’ awareness, attunement, and skillful response. Building on clinical experiences in Quebec (Canada), this paper questions the cultural safety of clinical interventions at three levels. First, the conflict can alter the therapeutic alliance in unspoken ways, requiring ongoing attention to cultural and contextual securitization. Second, because of its potentially traumatic impact, the conflict can influence symptom presentation in subtle or overt ways. Third, the internalization of the conflict can prompt forms of challenging acting-out, potentially eliciting stigmatizing clinical or social responses. Overall, preserving cultural safety in this context requires favoring a systemic assessment of the patient and their lived experiences, considering the family, school and community context. Minimizing silence and avoidance by addressing the possible distress and divisions or outright divergences within clinical and school teams may foster a respectful and safe enough environment, in spite of the differences in meaning within and across heterogeneous communities.

Within our globalized world, the proliferation of violence and direct online exposure to graphic and potentially traumatic images of ongoing war and other atrocities, including in Gaza, has important repercussions, with significant consequences for children, youth, and families from diverse communities (Franco & Boniel-Nissim, 2024; Leiner et al., 2016; Pe’er & Slone, 2022; Runze et al., 2022; Wang et al., 2006).

The psychological impacts of genocide (Carpiniello, 2023), displacement and war have been very well documented for decades (Carpiniello, 2023). Similarly, the impacts of censorship, silencing, or simple disengagement, have been documented both for victimized communities as well as those who work to support them (Chisholm & Sheather, 2018; Khan & Tinua, 2024; Lancet, 2025; Sowemimo, 2024). Fears of direct or institutional retaliation, loyalty conflicts and the potential that interventions could backfire and fuel local divisions may explain the tendency towards clinical silence regarding some forms of political violence at the individual level. At the system level, however, silence and institutional power are long-honed tools of colonial dominance where the stories and voices of the Other are, at best, undermined, and at worst presented as threatening or pathological (Fanon, 2015; Said, 1993; Smith, 2021; Thiongʼ;o et al., 1986). Impacted communities in long-standing Israeli-Palestinian conflict and the current war on Gaza carry multiple (and mostly conflicting) narratives of trauma and violence that have various generational and transgenerational implications. Within and across Jewish, Arab, Palestinian, and indeed other ethnocultural or national communities, the traumatic narratives of some are frequently held up to invalidate the narratives of the Other, or indeed to justify violence and mistrust of the Other, with resulting blind spots and/or legitimation of one’s own violence.

As practitioners, like those in impacted communities, we find ourselves at an intersection of distress and silence often enforced by our institutions, mirroring similar dynamics that occurred during the long list of humanitarian crisis and genocides of the last two centuries including those of the Indigenous peoples of North-America and elsewhere (Stevenson, 2012). The impact of the conflict and war extends far beyond the affected region. Preliminary data collected via an online survey among 1,182 Canadian adolescents attending public high schools in 2024 showed that 68% of youth reported being upset by the Israeli-Palestinian conflict. Higher distress related to international conflicts was associated with more depressive symptoms, and with higher levels of support for violent and non-violent activism (Miconi et al., 2023) suggesting that this context may lead to both internalizing and externalizing symptoms. Despite the emerging evidence, there has not yet been an acknowledgement of the clinical consequences of this context on the cultural safety of patients and clinicians within child and youth services. Coined in reaction to the systemic limitations of the concept of cultural competence, cultural safety emphasises the importance of explicit attention to historical and ongoing social factors that make the clinical encounter unsafe (Kirmayer, 2012). Based on clinical observations of clinical interactions in Quebec (Canada), this commentary reflects on some of the ways through which the cultural safety of the clinical encounter can be shattered by diverse reactions to the Israel-Palestinian conflict, by affecting the clinical alliance, symptom presentation, and through triggering youth resistance or acting-out. Proposing a reflective ethical stance rather than a set of guidelines, we acknowledge we do not have all the answers to a very complex reality. Yet, we propose how we might shift our clinical stance towards an examination of our own positionality, and engagement in critical reflection to mitigate some of the negative consequences of this context on child and youth mental health.

Clinical dilemmas are illustrated with vignettes, modified to preserve confidentiality, while preserving their core meaning. The positionality of the co-authors is important: Rousseau is a francophone, white child psychiatrist working in migrant and refugee neighborhoods. Kronick is also a child psychiatrist belonging to the Jewish community and working both with asylum seekers and with families in a Jewish neighborhood. Hassan is a Lebanese Muslim psychologist with extensive experience in refugee mental health. Miconi is an Italian child psychologist involved in school prevention programs in the Montreal region. The plurality of our identities facilitated a multifaceted sensitivity to the clinical reality we observe, though we are also cognizant that identities may be used to validate or invalidate epistemic authority, and that this too is part of the complexity of addressing the conflict.

When the Social Divide Shatters the Clinical Alliance

In our hospitals after October 7th, we observed an increase in reported tensions in patient-clinician interactions, including hate speech directed towards staff; refusals to be cared for by a clinician perceived of as the “enemy”; or avoidance and distrust by the clinicians themselves toward some adolescent patients or their families. This led us to pay close attention to subtler and more common alterations of the clinical alliance.

In already established alliances, we identified insidious transformations in dynamics when the patient-clinician dyad ostensibly represented opposite sides of the conflict (typically Jewish and Arab-Muslim). We noted increased attention to reassure the other, to avoid some topics, to express or deny anger in some cases, but also sometimes mounting distrust on the clinician or patient sides.

Mirroring the literature on underutilization of mental health care by migrant families (Measham et al., 2014), as well as that on cross-cultural misunderstandings resulting in ostensible non-compliance, missed appointments and non-compliance might, in this context, represent unsaid fear or distrust on the part of the patient. On the clinicians’ side, we observed a tendency for pathologizing interpretations of patient or parent’s behaviours.

Vignette 1

Presentation: A Muslim teen, followed by a Jewish child-psychiatrist for depression and anxiety symptoms, had an adverse reaction to SSRI, with the emergence of a hypomanic episode. The episode was misdiagnosed initially as conduct problems attributed to poor parenting. On closer examination, we learned that because the clinician found the parents distrustful, she was hesitant to thoroughly investigate family dynamics, for fear of being perceived as too invasive. Subsequent interventions revealed that, for their part, the family wondered if their child was being poisoned by her doctor.

Intervention: another clinician, called for a second opinion, was able to uncover the mutual difficulties in communication associated with feelings of cultural insecurity on both sides and to restore the therapeutic alliance.

Vignette 2

Presentation: A young Jewish child was in drama therapy, with a Lebanese art therapist who was viewed as “Arab” by his family, though the child did not necessarily know. After October 7 the child repeatedly tied up the therapist with rope and asked her again and again where she was from and if she came from a ‘good family.’

Intervention: The therapist did not react with fear, rejection, or retaliation, seeing this as a traumatic re-enactment and attempts to understand the Other. The child gradually worked through the repetitive play, and became more flexible in her play.

Because of the sensitivity of the issue, clinicians may hesitate to acknowledge and address the clinical consequences of this collective adversity for children and adolescents, as well as their own countertransference, and this can become a source of silent pain and inequity. Those situations require suspension of judgement and avoidance of circles of blame to decrease the tensions and preserve a safe enough therapeutic space (Rousseau et al., 2022). While often proposed as a solution, ethnic matching may increase mutual comfort but can also fuel the perception of the out-group as a threat. As described in the two vignettes, addressing the fact that the therapeutic alliance can persist despite world turmoil, either verbally or non-verbally, is a first step to work through the tension that may emerge from conscious or unconscious assumptions. In both cases, reflecting directly on the clinician’s countertransference and potential blind spots with another clinician was also helpful.

An Adverse Context Which Transforms Clinical Presentations

We observed that the unregulated exposure of children and adolescents to graphic representations of war and the internalization of their family and community reactions provoked the emergence of new symptoms, and increased or modified pre-existing symptom patterns. First, a range of internalizing problems were manifest. Because families, youth or parents sometimes perceived schools as potentially unsafe, and because young people often wanted to take care of parents at home, school phobia and absenteeism appeared to be on the rise for directly involved communities. Concentration and attention difficulties were also noted, with concomitant manifestations of diffuse anxiety, particularly in children whose extended family lived in the Middle-East.

Vignette 3

Presentation: A Muslim boy in kindergarten was brought to consultation because he had developed significant tantrums in the early morning and his mother was unable to bring him to school. Assessment revealed that a few weeks prior a man had spit on the mother while she rode a city bus with her son, wearing a hijab. When the frightened boy had asked about the incident, she had minimized it. The parents regularly watched the news in the evening, and the mother reported crying often because of her distress felt for Palestinian children.

Intervention: Parents were advised to decrease the exposure of the boy to the news, and to explain to him in a reassuring way that he, his mother and his family were safe, even if sometimes people were not nice. After a few parental support sessions, symptoms subsided.

Second, we also encountered non-specific oppositional and conduct manifestations in elementary school children and more specific provocation reported in adolescents. Identity affirmation through clothing (colors and symbols) or flags was commonly considered a problem by high schools, though we found that school rarely acknowledged the ways their policies or messages often implicitly endorsed the government narrative about the conflict, and thus, in a sense, was seen by students as ‘taking sides’.

In our experience, addressing family, peer, school and community contexts in truthful ways, while acknowledging the sometimes irreconcilable divide, could sooth to some extent the distress and contribute to de-escalation of local conflicts. For, example, when bringing the two groups together was not possible, our team would still lead separate spaces for Jewish and Arab students to speak openly about their distress vis a vis the school climate and institutional policies. Understanding and legitimatizing emotions, unsurprisingly, played a key role for children, their families, as well as for the involved professionals.

Finally, reminding parents to reduce youth exposure to traumatic images in the online environment is a fundamental priority (Browne & Hamilton-Giachritsis, 2005).

Responding When Youth Act-Out

In North America, diverse forms of discrimination and hate events increased after October 7th and the intensification of the war on Gaza (Brym, 2025). For example, anti-Palestinian racism toward healthcare providers was found to increase (cite https://antipalestinianracism.org/pr-study-documents-systemic). In our clinical services, the number of adolescents referred to services because of perceived risk of violence or hate speech (Anti-Semitic, Islamophobia, anti-Palestinian and anti-Arab racism) also sharply increased after October 7th, 2023, raising two main challenges. First, what constituted a developmentally appropriate manifestation of anger, protest or loyalty in youth versus what needed to be condemned as toxic hate discourse was a source of disagreement among team members. This mirrored the profound social polarization around what is or is not acceptable to say about the conflict. Second, we found that implementing solutions based on understanding and rehabilitation of youth perpetrators encountered more resistance from community and schools than in our other work because of the feelings of moral injury amongst school teams and of the heightened emotional involvement. The following vignettes illustrate possible clinical presentations of these issues.

Vignette 4

Presentation: A 12-year-old Muslim boy posted a swastika on social media because he was upset about the bombing in Gaza. He had never been hateful, violent or aggressive in class but was directly expelled from school without recourse to mediation, though he expressed remorse and willingness to apologize.

Intervention: The clinical team sought to validate the school’s visceral responses to the swastika, while encouraging repair so that the boy could reintegrate in the school where he had attachments to friends and teachers. The school would not allow him to return. The clinical team shifted support to the family, the boy, and eventually to the new school to make sure he would not be stigmatized. Ultimately, he did well in the new school, albeit mourning the loss of previous attachments.

Vignette 5

Presentation: A school social worker trainee who wore a hijab was called a terrorist by a 10-year-old Jewish boy who insulted her and refused to remain in the classroom or hallway if she was there. When contacted, the parents justified their son’s position, arguing that it was understandable given what “those people” were doing.

Intervention: The intervention supported the trainee and addressed the racism and prejudice against Muslims, as well as the highly emotional context because of the war. Unfortunately, no follow-up intervention was possible with the family.

In these situations, a systemic clinical formulation and associated intervention helped to preserve-where possible-a reassuring climate while not fueling the anger and fostering more marginalization (school suspensions). This was a very delicate endeavor, with both successes and significant failures. In such situations, a restorative justice approach proved to be useful to consider in an equitable way the diverging voices of youth, family and communities (Moore, 2022). Because dissent often prevailed, patients, families and teams had also to mourn, at least partially, their expectations for dialogue and mutual understanding. Given the level of politization of emotions, the promotion of double empathy (or empathy across both conflict-affect populations) and dialogue, although ideal, remains difficult to attain (Santavicca et al., 2024) and clinicians’ goals should be to minimize the hurt and subsequent chain of negative events.

Risking Self-Reflection, Dialogue and Dissent in Clinical Services

Although we learned a lot from examining the impact of this terrible conflict on our clinical work during the past year (Santavicca et al., 2024), we also realized that available clinical guidelines did not provide simple answers to address a profound social divide which was affecting clinical teams and schools, limiting their capacity to hold safely children and families. We believe that a respectful acknowledgement of the legitimacy of the hurt and distress on all sides can be useful in helping contain the fear and address the discontent stemming from polarized institutional and political positioning (Lamont, 2023). While distrust, anger and violence become more prominent among children and youth who feel unheard, silenced, and deprived of agency, this may also happen within teams of professionals and educators, and may undermine collegiality and collaborations around conflictual situations. In such a tense context, what is the role of clinicians? Some of us will suggest that neutrality, enacted by remaining strictly within clinical duties, should be privileged. Referring to the historical lessons stemming from Second World War, the Holocaust and the colonial past, silence can sometimes be a form of complicity that can contribute to jeopardizing patients’ sense of protection, and as a group we believe that advocating for the respect of international human rights conventions, including the UNConvention on the Rights of Children, is part of our clinical mandate to prevent harm. Nonetheless, we are aware that some may be uncomfortable with our stance, given that even these international bodies are themselves highly contested in the present context. Any ethical reflection is rooted in the examination of a delicate balance between benefits and harms (Young, 2016), which entails a subjective positioning. Inspired by context-specific experiences, our aim is to encourage dialogue, opening a space for professionals to share experiences, successes and failures. We hope that expressing both disagreements and how we are touched and moved by the present world events can be a way to enhance our collective capacity to move beyond silence and avoidance of moral-political tensions as they reverberate in the clinic.

As clinicians, we feel we need to address the discomfort, re-examine our positionality and reflect on key concepts such as neutrality and advocacy as these will be challenged by our patients. This entails re-examining the relationship between our diverse historical traumas, our intersecting identities, our privileges, and the way they impact our alliance with children and families.

ORCID iDs

Cécile Rousseau https://orcid.org/0000-0002-6533-6774

Diana Miconi https://orcid.org/0000-0002-7088-1646