Photo: Valerie Babize / MSF

What is the focus of the program in Gaza?
The population in Gaza lives in a state of siege due to the inter-Palestinian conflicts and the conflict with Israel. The violence hits the civilian population hardest. Most border crossings to Israel are closed.

MSF started setting up post-operative clinics in June 2007. Also a paediatric project started last March in Beit Lahiya, in the northern Gaza Strip, to treat children under 12. I have mostly seen young men between the ages of 18 and 35 in treatment, who had been operated on previously and who now need aftercare. We apply new dressings and do physiotherapy.

Due to the violence, the isolation, and the occupation, as well as a lack of personal prospects, many people in the Palestinian Territories are traumatised. They can’t visit relatives in other parts of the country and can’t attend funerals. The population lives in fear and is constantly threatened by ground and air strikes.

For these traumatised people, MSF opened a psychosocial-medical program to alleviate the psychological suffering following exposure to violence related to the Israeli-Palestinian conflict or intra-Palestinian conflict.

What are the symptoms of the trauma?
Seven years of intifada and decades of occupation have brought what we could call “multi-wave” traumas for the population, which can impact individual, social, family and professional lives.

People suffer from acute stress reactions or, if the event lies further in the past, from posttraumatic stress disorder. This is a delayed reaction that can develop after exposure to terrifying events in which grave physical harm occurred or was threatened. The traumatising event can come back like a film, which the affected person can’t control. These flashbacks are partly responsible for symptoms like insomnia, loss of appetite, shock reactions, and fear of going outside. With children there can also be bedwetting, loss of concentration and learning disabilities.

Moreover, physical discomfort without medical causes can occur, like headaches and temporary paralysis of extremities. To the psycho-traumatic reactions mentioned above, many losses will be added: loss of relatives, loss of psychological and physical integrity, loss of one's home and belongings, loss of professional and social roles. All the disruptions due to the trauma will make it difficult to properly mourn these losses and will often lead to deep and persistent episodes of depression. People may also exhibit behaviour like withdrawal and self-harm.

How were you able to help the patients?
I work as a behavioural therapist and also use clinical hypnosis. With behavioural therapy, the focus is on encouraging self-help. In Gaza it was about teaching patients methods to overcome stress. This begins with learning a breathing technique which lowers the heart rate and the electrical resistance of the skin, thus relaxing the body. Athletes do the same before a competition.

Having reached a state of relaxation, the patient works on regaining resources, finding a positive outlook and converting bad memories. A patient who was shot at a specific corner might still be afraid to go there, even when there is no further danger. His fear comes from the reactivation of the emotional trauma of injury. When the patient is relaxed in a session, he can return in his mind to that corner, free of fear, and imagine how the place felt before it took on a negative connotation. Then the same is done while picturing the place in the future.

Traumatised people are in an emotional black hole and don't have access to positive experiences.

How does the treatment work?
Patients are mostly referred by the post-operative clinics, though many come through self-referral or through other organizations working in Gaza. A session takes about an hour.

Eight to twelve sessions are often enough to make the patient able to sleep, eat or concentrate again. The sessions work to decrease symptoms and help the patient acquire enough conscious understanding to overcome future problems.

Therapy can also help to treat the mental aspect of a physical disorder. I once had a young widow in the clinic. Her husband had died as a “martyr” and her brother-in-law died a violent death as well. Then her father got sick and eventually died with a broken heart.

The widow came to me complaining of insomnia. It was triggered by a number of causes: she lived in constant fear of attacks, and she was afraid that her son might want to become a “martyr” as well. She wasn’t able to process the loss of her husband.

On one hand there is pride for the “martyr”; on the other hand she is left alone in a society that doesn’t offer many prospects for widows. I taught her how to use breathing and imagination techniques whenever a stressful situation arises. After a while she was able to sleep again.

How did you perceive the general situation in Gaza?
I haven’t seen much of Gaza. I was only able to work in consultation rooms due to security restrictions. The population of the Palestinian Territories are quite open to therapy.

Additionally I had the advantage of being a foreigner. Gaza is a small place and everybody knows everything about everybody. It was easier for patients to speak openly to a stranger.

The situation is appalling. Next to violence and isolation there are also electricity shortages. There is a lack of everything. This makes it even more amazing that people deal so well with physical and emotional threats over many years.