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Dr. Moshe Lachish, Child and Adolescent Psychiatrist,
Dr. Shani Lior-Avin, Rehabilitation Psychologist
Vivian and Seymour Milstein Children and Youth Trauma Center,
Children and Youth Psychiatric Services at Soroka Medical Center,
Soroka University Medical Center, Beersheva

And the angel of God, who went before the camp of Israel, removed and went behind them; and the pillar of cloud removed from before them and stood behind them; and it came between the camp of Egypt and the camp of Israel; and there was the cloud and the darkness here, yet gave it light by night there; and the one came not near the other all the night. [Exodus, 14:1920]

Just about 4 p.m. on November 14, 2012, when Ahmed Jabari, commander of the military wing of Hamas was killed, the Israel Defense Forces commenced Operation Pillar of Defense (or literally the Biblical ‘pillar of cloud’) in the Gaza Strip. The operation ended a week later when a ceasefire was called on November 21, 2012. Thousands of targeted attacks were made on Gaza as thousands of rockets were fired on Israeli communities, but there was no ground operation.

We could have written about our work during those days in a dry academic style, distanced from the events. We could have written about it or around it, but since we chose to focus on the entry of the military operation “Pillar of Defense” right into the treatment room, like a cloud situated in the middle of things encompassing everyone, we felt that we must convey the very special experience of the therapist in this situation. For literary purposes the following is written in the first person feminine. All the details are true.

Wednesday, November 14, 2012, 3 p.m. The session with P. is about to end. P. is a 13 year old girl living with her family in Beersheva. She was referred to our clinic due to severe anxiety accompanied by significant dysfunction that started with Operation Cast Lead (December, 2008). She fits the diagnosis of post-traumatic stress disorder (PTSD); however, is it reasonable to speak of “post-trauma” when the stress is continuous and every escalation of the security situation causes an exacerbation of the symptoms and reduces hope for improvement?

In this session P. relates that again she did not go to school today because she feared there would be an air-raid siren. It seems that the logic of my cognitive solutions is not sufficiently persuasive to overcome her limbic fears. I try a more behavioral approach — that until our next session she will measure the time it takes her to get from her classroom to the shelter. Suddenly the sounds of a helicopter landing on the hospital helipad are heard outside. P. immediately stiffens and looks at me anxiously: “Something bad happened”. I smile at her and use the opportunity to point out her characteristic catastrophic line of thought. Maybe it’s a drill? Maybe it’s a VIP coming for a visit? I never would have guessed that in just a few days I will have to phone her to ask how she is doing in the shelter and then it would be her smiling at the other end of the line, saying “I told you so”.

At 4 p.m. I leave the clinic to go home and when I get into my car I get a text message “Due to the situation, all the local after-school clubs are canceled today”. Ugh, I say to myself — What now? Can’t we have a little peace and quiet? I turn on the radio and on my hour-long drive home I find out about “the situation”. It was even already given a name and categorized, Operation Pillar of Defense. It’s serious, it’s for real. The tension mounts as the trip progresses. I find myself looking up towards the sky, more than at the road, searching for threats. My children’s babysitter notifies me that they didn’t leave the sheltered kindergarten and they are waiting for me there. I take comfort in knowing that it is bombproof, but I feel terrible about my inability to be there with them, to protect them and provide a sense of security. When I finally arrive they run to me all excited and pale and tell me about all the loud ‘booms’ they heard. Now it’s quiet so we hurry home by way of a preplanned route that passes by improvised shelters and places to take cover.

My personal war has been going on for a long time. A fierce battle is taking place on the front. For the past several years mortar shells and trajectory missiles have been flying over my house and the surrounding fence has been breached and attacked. The world of colors has taken on new meaning. The world of associations has become morbid, even the notion of “a safe place” or “my house is my castle” has been eroded with time. Paradoxically, my work place in Beersheva became, for most of the time, a type of safe haven for my patients and myself. The Children and Youth Trauma Center where I work is a small quiet corner in the hospital. There I find my office to be quieter and more comfortable than where my own children are. The larger the gap, the greater the tension and divergence between the interior and the exterior. This war is long, but apparently not so intensive, like a drawn-out headache, piercingly quiet — a constant alertness in anticipation of the inevitable transition from routine to emergency. Apparently the only way humankind can deal with it is to join both of them into “Emergency Routine”. The radio tells me to make the transition, right now, without a moment to spare. In another week, with the declaration of a ceasefire, I’ll be expected to reverse the transition, to switch back to routine; once again, immediately, without hesitation, but the body has its own rhythm. The psyche too.

This war caught me, as always, unprepared. At the flash of a single text message you can find yourself holed up at home, just 15 seconds away from the bombproof room. Most of the time you are imprisoned in it, with the chief jailer the fear for your children and family’s safety, howling explosive echoes, like an obsessive public address system. Long years of experience and repeated incidents did not make me any more immune nor stronger. I can’t get used to the idea that they are shooting in my direction, at me. I haven’t gotten used to the idea that danger is always lurking, and that there isn’t anything I can do to avoid this feeling. We took advantage of the first few hours when both sides were getting organized for the coming events to get organized ourselves. I went with my family to Tel Aviv, to my parent’s home. The next day we trembled as we heard the air-raid siren in the Tel Aviv metropolitan area and as I looked into my children’s frightened faces, I was shaken by the thought, ‘here too’, ‘here too’.

Mornings I drove to work in Beersheva. The way was so long, fatiguing. Looking at the road, the sky, contemplating where would it be more dangerous today. On the road, just like when I’m at home, children’s names run through my head. The youngsters who are currently under treatment in the clinic, youngsters who completed treatment, youngsters who contacted us recently and are awaiting an appointment. My heart is with them, with myself, with my family. The work at the hospital helps and assumes a central role. Wearing the therapist’s hat is a commitment, but the head that wears the hat like an open wound wanders in many places. I think about my personal experiences, about the continuous exposure to the traumas of the children treated at the clinic, the endless exposure at home, the reality that turns the treatment topsy-turvy. Again a long list of children treated at the clinic for security-related traumas runs through my mind. Patients who only now came to the clinic with dysfunction issues that started with Operation Cast Iron. Patients who only now have started to feel better. Everything is so fragile. A siren blares, the body reacts immediately, and then the apprehension sinks in. Sitting in the shelter I hear the echo of the blasts, maybe those we intercepted, maybe those that fell nearby. I can’t differentiate, but a psychologist near me says he can. He can even tell if it fell in an open space or built-up area. I think to myself what reeds in the wind we attempt to grasp at to seek a bit of control. I wonder whether the blast-waves that shake the walls of the shelter are strong enough to destroy them. These thoughts mingle with the voices of the hospital employees’ children who are staying in the shelter so their parents can come to work. Does the fact that they are closer make it easier for the parents to concentrate on their work? Does it relieve even a small amount of the vast realm of fear and uncertainty? Ten minutes pass. I return to the clinic.

One of the days I’m called for consultation in one of the pediatric departments in the hospital. I meet an adolescent girl who came due to physical complaints of abdominal pain and nausea. The medical staff took note of a very high anxiety level. I find her lying on the bed in one of the rooms in the bomb-proofed section of the ward. Her parents and boyfriend are with her. The boyfriend goes out to the hallway as a group of ultra-orthodox girls go by, wearing smiles as they distribute treats to the hospitalized children. After a few minutes of conversation with her it becomes very clear how wrapped up she is with the security situation. I begin to explain that she is in a safe place now — but just then the room reverberates with the unnerving sound of a siren penetrating the closed window. The girl runs to the corridor, screaming, pushing aside the frightened group of girls. I go out after her, trying to call her, and a few moments later she is returned to the ward’s sheltered area by her boyfriend. Shaking, she stands with all of us waiting for the boom that takes its time coming. The frightened girls are breathing rapidly, and other patients crowd around, some calm, others not. Some look toward the staff, looking for calm or studying their reactions, others are totally wrapped up in themselves. Apparently panic can be added to the list of contagious diseases in the department. Some demand quiet, some cope by chattering away for distraction. Ten minutes pass. We go back into the room and the girl repeats that she heard two explosions. On the television, which she refuses to turn off, they report that it was a false alarm, but she isn’t convinced. I abandon the use of interventions offering psycho-educational information on reactions to trauma and instead try relaxation techniques. Offering tools that I hope she’ll be able to use when needed. After reaching an understanding that the body speaks for the soul and it may be wise to let the body talk back to the soul, I leave, carefully planning my route back to the clinic, noting where I can take refuge, where I can run to reach a shelter.

Very few come to the clinic at this time. Who does come? What does it say about them, about their condition? Maybe it says something about the place where the treatment is given. About the feelings that the place arouses. Perhaps it even confirms the vulnerability of every single place. An absolute impotency? What does that say about me? Did I try to protect him sufficiently or perhaps I should have told him not to come, to comply with the Home-Front Command directives and stay home? Am I able to contain the fears of others when I myself am overflowing? Can an analyst in the therapy room be compared to a soldier on the battlefield who has to maintain the capacity to think ‘under fire’? But what happens when the treatment room is part of the real battlefield? Can the treatment room be considered a potential battleground where the analyst has to think about the reactions and the attacks of the patient? The home-front is the battlefront. Just how much can one listen to inner workings when the roar of the cannons and the shrieks of the missiles reverberate outside? I think about one of my girl patients, about her limited opportunities to play in the room. Terms come to mind, “Winicott”, “Transitional space”, but the only space that comes to mind during the therapy session is the lack of a bombproof space in her apartment. The objective reality demolishes every bit of imagination, diminishing the potential.

And what will happen if there is a siren during the treatment? I mull over how I’ll feel with my regular patients in the shelter when I myself am totally exposed. I wonder how transparent I am, if they can sense my thoughts? Fantasies of salvation battle with the real desire to worry about my family and myself. Will I be a pillar that they can grasp for support, follow? Or perhaps a thick blinding cloud? I remind myself that I already experienced similar situations when I worked at the clinic in Sderot, abruptly stopping treatment when the “Color Red” warning siren sounded and rushing with the patients to a protected corner on the second floor near the restrooms. It seems that in those moments, when the treatment venue is attacked by the objective reality, the therapist figure itself is what holds the framework together, indifferent to time and geographic location. But perhaps I am mistaken. Can I, like the “Iron Dome” protect personal vulnerability from the external dangers or is that merely an omnipotent thought that ignores both the external reality and my own inner one?

And perhaps the next siren will be the forerunner of a mass of people coming to the Emergency Room. Will I be called to the ER to treat shock victims? Will I be able to offer the proper response for each and everyone? And when it’s all over, how will I cope with the constant trickle of disbelieving patients, patients whose lives have been put on hold at this moment or another? When there are no patients the quiet allows the inner voices to be heard. The voices are accompanied by tension and vigilance. Lots of scenarios rush through my mind. I don’t let the noises overwhelm me. I sit with the list of patients and phone to ask how they are doing. Remind them of the resources and coping methods. “Where do you live” they ask and I wonder what they want to hear. That I’m protected? That I’m afraid like them? That I too didn’t sleep all night because there was a siren every hour? That it’s okay to go to places outside of the danger zone, if there’s such a place in our country?

The operation ended with a short declaration. On the way to work the fog is waiting for the sun to disperse. I still divide my attention between the road and the sky. “Here, this is where I stopped the last time there was a siren”. A jet plane leaves a white wispy trail, and I conjure up images of the missile interceptions that painted white lines in the blue sky — as Israeli as it gets. I know that when I reach the clinic patients will be waiting for me, those who decided to believe that it is over. Others will require more time to admit that they cannot yet ‘come back to themselves’, to see me look into myself, hesitating about how much to share, and to say to them and to myself, “It’s normal, it’s normal”.

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