Michael Michalik"It will take time for the healing to begin" - A psychologist's diary treating mental trauma in Gaza

Clinical psychologist Michael Michalik worked for the international emergency medical aid organization, Doctors Without Borders/Médecins Sans Frontières (MSF) in the Gaza Strip for six months in late 2003 and early 2004. He is part of a mobile team that works with families most affected by the continuing violence; people traumatized by the relentless threat of gunfire, bombings and demolitions. Dr. Michalik wrote this diary of the events and patients that dominate his work. This week, the subject is Mona, a woman struggling to overcome dark fears and a sense of helplessness.


As with so much of our work here, there are real limits to what you can hope to achieve. I know I make a difference to how some of the patients can cope with their very difficult lives.

– Michael Michalik



Friday November 14, 2003


It's been a difficult few days; they often are for the people here in Gaza. Back on Monday, our coordinator was in the southern area of the Strip in Rafa when the Israeli army went out on the streets with tanks and bulldozers in one of their incursions. There was heavy shooting and disruption. I was due to be in that same area the next day, so she briefed me about where the hot spots had been in relation to a couple of families that I visited regularly.

When I reached them on Tuesday, they had been in the thick of it. The family I knew best, and had been coming to for the last three months since I started here in Gaza, are terribly exposed. Their house has an Israeli military watchtower looking down at it and homes have been demolished all around. There's shooting very regularly and the inside walls of the house are covered in bullet scars. I find twisted bits of metal scattered on the floor. Most of the gunfire happens at night and the parents have to take their seven children out of the bedrooms into the most protected bit of the house - a storage area on the first floor where the bullets don't reach. There's room for the children to lie down, while the mother and father only have space to stand or sit. Not that the kids can sleep with the gunfire anyway.

It's their eleven year old son ( I will call him Ahmad) who is my main concern. He has become uncontrollable and his personality has been changed by the violence. Ahmad keeps putting himself at risk by running out to try and rescue things from houses that are being demolished by the Israelis. He is obsessed with it and yet it is so dangerous with the tanks and bulldozers firing as they work. The last three years of the new intifada and constant fighting have taken a great toll on children here. Ahmad's schoolwork has declined and he has become so aggressive that even his friends are afraid of him.

My sessions with him are an attempt to drag him back from the most risky bits of behavior. I try to reinforce what his parents tell him about his duty to them and the community. I've been working with family problems and difficult children for many years but this is especially hard. He does seem to want to listen, to take advice from this strange foreigner. He agrees with me that he must support his mother and his brothers and sisters and that means not getting killed. We talk about a future in which he helps his community by getting qualified as a doctor or a lawyer. But then he says to me, "I know I could be shot but I have to go and help these families who are being attacked. I don't feel safe in our house anyway and I would prefer to be a martyr."

This week, that was the fate of a neighbor's child. A fourteen-year-old friend of Ahmad's was shot by the Israelis in the chaos of the incursion on Monday. Ahmad told me how three of them had been on the street when this boy was hit by a bullet in the abdomen. He was bleeding badly and the ambulance could not get to him. A taxi finally took him to hospital but it was too late.

Ahmad's reaction was disturbing in itself. As he told me about the awful thing he had seen, he had a kind of forced detachment, a nervous smile that was completely inappropriate. All this new horror was probably a major setback for attempts to re-direct his behavior. There have been good weeks when he seemed to have calmed down and when our talks about homework and supporting his family appear to have had some effect. But I know that the only thing that will rescue him is if he and his family can move away move away from the front line there and the repeating trauma that is so damaging. As with so much of our work here, there are real limits to what you can hope to achieve. I know I make a difference to how some of the patients can cope with their very difficult lives. That is not enough for Ahmad.

Wednesday November 19, 2003

I have had three consultations with Mona and gradually I have come to understand her enormous strengths and at the same time her vulnerability. Mona is in her late thirties, perhaps early forties who is suffering from what is called post-traumatic stress disorder. It's a cluster of symptoms, some of them appearing as physical, like aches and pains and sleeplessness, some of them are emotional and behavioral disturbances.

Mona has nightmares, an eating disorder and a terror of gunfire, even when she sees fighting on the TV news. She has been treated for depression and has a difficult medical history going back two years. It was one incident that set it all off. At that time she was living right in the thick of the fighting and demolitions here in Gaza. One day there was a huge explosion near her house and everyone knew that a young man had been hit. But despite searches, they couldn't find his body. Mona had been out on the street looking herself. When she came back into her courtyard she almost fell over body parts that were all that was left of the victim. That trauma has stayed with her ever since.

Until that moment Mona had adopted a dangerous but apparently effective way of controlling her fears of the violence surrounding her. She took extreme risks on behalf of the families in the neighborhood, which was constantly under fire from Israeli soldiers. She developed ways of facing down their threat. For example, one of the soldiers' favorite targets has been the water tanks on the roofs of the houses. They try to drive people out by draining the water and the local men know they risk being shot if they go on the roofs to repair the holes. Mona began to act as their human shield by going up herself. The Israeli soldiers would not fire at her and the men could follow to fix the tanks.

It was the same with journalists, who were fearful of getting caught in the gunfire but anxious to report and film the latest events. Mona became their guide and protector by walking ahead of them with a handwritten sign saying "Press".

She explained to me that she felt no fear and was convinced that this was her duty to the local people. It was her way of asserting control over the thing she feared and gave her a sense of outwitting the enemy.

As she told me about this, I realized that it could be turned into a weapon to fight the inner battle that still tormented her. It showed what enormous resources she could summon up. What I said was, "We are going to use this strength and courage within you to overcome your remaining fears. I can see from your face when you tell me the story of your time on the front line that you can feel the power you had then. We will recapture this spirit and use it to push against your fears."

Mona needs constant encouragement and praise. And we are already making some progress. After these three sessions, her nightmares have stopped and despite her stomach pains, she is beginning to eat a little more. It will take time but just like strengthening an injured limb, if you can find the right exercise, the healing will occur.