Alive, but only just

One of the patients the team highlighted at one of these afternoon meetings was Amal, a man in his forties who arrived at the hospital a few days into the ceasefire in January 2025. He was seriously injured, with a lot of shrapnel in his body, fractured arms, and legs, emaciated and with a lifeless facial expression. Several members of the MHPSS team had noticed that this man was in severe physical pain and that he also seemed to be suffering from a great deal of psychological pain. He was a patient we would probably have to monitor closely, concluded the MHPSS volunteers from the Palestinian Red Crescent Society (PRCS).

The medical team told us that Amal would probably have to stay in the hospital for at least two months. We discussed the case, and Mahmoud, who works as a psychologist at the hospital, said that Amal had been a little dismissive of him so far, and that it was now a matter of building the patient’s trust in him. Mahmoud wanted to show that he cared so that he could eventually foster a more therapeutic alliance. Mahmoud visited his bedside and greeted him every day. Surgical interventions, food, drink, and medication began to have an effect after a few days. Amal was able to tell the volunteers that he was in a lot of pain, that he was worried about his family, that he was very afraid of what would happen next, that he slept poorly and that he had painful memories. The volunteers offered him a phone so he could call his family and helped him find people who could find out how he could reach them.

After a couple of weeks in the hospital, during which Mahmoud greeted and chatted with Amal as he did with the other patients, Amal agreed to talk to him. During this session, he told him about all his physical pain and about what had happened. His house was in an area that had to be evacuated, but he was unsure whether the order still applied to the area where his house was, and he went back to his house together with friends. He wanted to see what it looked like after the fighting that had taken place in the area and to see what was left of his belongings. While they were inside the remains of what had been his house, they were attacked. Two of his friends died, and he himself suffered explosive injuries to his leg, foot, and arm. He lay there unable to move for several days, and dogs tried to eat him. Intense fighting was going on around him, both in the air and on the ground. When a ceasefire came into effect, other people entered his neighbourhood and found him there. They called an ambulance, which brought him to the hospital. Amal went on to describe how he now had nightmares of dogs coming and biting him and of seeing his dead friends lying around him. These nightmares disturbed his sleep, which in turn caused him to experience more pain during the day.

We discussed the case in our team and agreed that the most important thing now was for the patient to understand that he was relatively safe in the hospital (we could still hear sounds of hostilities throughout the day and night), that everyone at the hospital was doing their best to help him heal, and that he could trust the medical team. The volunteers in the MHPSS team were tasked with checking on him daily, inviting him to play games and encouraging him to take trips in his wheelchair whenever he could. All this was to show him that we cared and wanted him to get well, and to distract him from the pain. Patients at the hospital are accompanied by a relative who can help them with non-medical care, and these people sleep at the hospital. The MHPSS team were also to follow up with the relative who had accompanied Amal to the hospital, so that relative could express any frustration or hopelessness to the volunteers, and support Amal in the best possible way. Mahmoud was to continue with individual sessions two to three times a week. The team collaborated with the medical staff on managing Amal’s pain medication, making necessary adjustments along the way.

A wounded victim or a surviving hero?

In our discussions, Mahmoud told Steinar that Amal seemed to enjoy talking, while repeating the things he had said in the first session: nightmares about dogs, pictures of his dead friends, pain, and lack of sleep. He appeared sad and lacking in vitality, as Mahmoud saw it. Session number three was very similar to the previous two. It was as if he was stuck in that part of the story, said Mahmoud. The more we discussed the case and took in what Amal had been through, the more amazed we were at how he had managed to survive these incomprehensible events. Mahmoud was reminded of reframing from his CBT training and said that perhaps the approach for the next session could be: ‘How have you managed to survive all this?’ We both felt increased energy and hope at this idea and were excited to see how it would go. In an enthusiastic and hopeful tone, Mahmoud said that he would reschedule the sessions that day because he had to try this right away.

Later that same day, Mahmoud came to Steinar with a big smile on his face and said that Amal was truly a hero. It was unbelievable what he had been through and survived. The reframing intervention had helped Amal to tell a completely different story. After his friends had been killed, he saw how badly injured he was and improvised a dressing for his wounds to stop the bleeding. He moved from where he was to the remains of another house nearby which he thought would provide more protection from bullets and explosives. At the same time, he had to fend off dogs that wanted to eat him. He found some alcohol in the ruins of the house, which he used to clean his wounds. Despite the pain, he soon realised that he was thirsty and had no water. He then found what had once been the bathroom and found a few drops of water in the water pipes with which he was able to moisten his lips. He did not want to drink any more water out of fear that he would bleed more. Amal remained inside the house, hiding from anyone and anything that might spot him from the air or on the ground. On one occasion, he thought he had been discovered, and he had to lie completely still and pretend to be dead until the danger had passed. When the pipe ran out of water, he had to move on. In another house, he found a bottle of water that was half full, and that kept him alive for a few more days. Mahmoud said that Amal spoke with enthusiasm and courage, and smiled several times as he recounted what he had survived. Knowing what life was like outside the hospital when the fighting was going on, Mahmoud found it difficult to believe Amal’s account. He chose to praise Amal for his courage, creativity, and will to live.

Steinar could see that something had happened to Amal. He made more eye contact than before, smiled, and held his hands for a long time in gratitude every time he walked past his bed. Mahmoud said that in subsequent sessions, the nightmares about dogs and the intrusive images of his veins were no longer a topic of discussion, as they had been in the first three sessions. Amal told Mahmoud that during the days he fought to survive, it was his love for his children and concern for his family that gave him the energy and will to carry on. Further sessions revolved around Amal’s relationship with God, his regrets for things he had done earlier in his life, and his desire to live a better and more righteous life in future. He also talked a lot about difficult issues he had experienced with his parents as a child. In particular, he deeply regretted situations where he had been rude and disrespectful to his father. In addition, his physical health was always part of the sessions: pain and joy, his motivation to walk again, his concerns for the future and how he could take care of his family. He always thanked God sincerely for his life and health.

As Amal grew physically stronger, the volunteers and Mahmoud worked together with the medical team to motivate him to stand on the leg that had been badly injured. It was a joyful moment for everyone when he took his first steps. Once again, Amal thanked God sincerely for healing him and saving his life. Amal became an important source of inspiration for other patients who came to the hospital, and he helped the MHPSS team build relationships with patients who found it difficult to trust the team members.

When Amal was to be discharged, we asked him what effect his sessions with Mahmoud had had on him, and he said that it had been a very positive experience. He felt proud of what he had achieved when he realised what he had survived, and that he had now managed to recover enough to continue taking care of his family. He had felt safe and comfortable during the sessions, and he had once again realised that he had a lot to live for. Finally, we asked him if we could share his story and his work with Mahmoud with the outside world. Initially he was hesitant, but consented once he was assured that everything would be anonymised and that there would be no pictures of him anywhere.

After our hospital had done what we could for him, Amal was to be transferred to another hospital. A few days after he was discharged, the hostilities resumed, and the offer he had received from the other hospital disappeared. Like the Red Cross field hospital, this hospital now had to prioritise life-saving surgery. The last we heard of Amal was that he was at home and came to the hospital for wound care at irregular intervals. He was hoping to receive the remaining operations he needed to be able to function as well as possible, and was worried about how he would feed his family. Like everyone in Gaza, he was afraid that neither he nor his family would survive.

Witnessing and accompanying hopelessness

Amal’s story is just one of an overwhelming number of stories about inhuman suffering, both physical and psychological, in a brutal context. All over the world, extreme contextual stress has major consequences for mental health. As psychologists, there is often little we can do about the specific living conditions of individual patients. It is then easy to become paralyzed by everything we cannot do anything about and to be overwhelmed by the hopelessness the patients feel. This can lead us to overlook contextual factors that we can do something about. It is also easy to forget that, regardless of the limitations the patient faces, we can always be a fellow human and companions in suffering. Being there, persevering, and enduring the hopelessness together will usually lead to a strong relationship between the psychologist and the patient over time. At its core, the relationship is not primarily therapeutic, but human. And then, at some point when you least expect it, such relationships, together with simple interventions, may help to bring out the person’s resources and help them to persevere and find solutions that we could not foresee. The big challenge is to persevere, to remain in the relationship even when we want to give up or give in to hopelessness. While we are companions in suffering, it is important that this companionship always goes hand in hand with active efforts to find solutions to the structural causes of the mental health problems experienced by the patients we meet. Striking this balance is rarely simple, emotionally easy, or obvious, but that makes it all the more important.