My article in The Counter Terrorist magazine – April / May 2017
PTSD in Israel’s Defense Forces is among the lowest in militaries worldwide
In 2013 the Israel Defense Forces Medical Corps Mental Health Department released a study on post-traumatic stress disorder (PTSD). According to the study, reported cases of post-traumatic stress disorder among Israeli soldiers are among the lowest in militaries worldwide.
For example, following the 2006 Second Lebanon War, 1.5 percent of Israeli soldiers in mandatory service and in the reserves were diagnosed with PTSD. Some 2.9% of the servicemen who took part in the military campaign sought psychological help after the war, but were not diagnosed as suffering from PTSD. In contrast, a U.S. Army Medical Corps study done in approximately the same time period found that about 8% of U.S. soldiers who served in Iraq and Afghanistan had been diagnosed as suffering from PTSD.
According to the IDF study, PTSD diagnoses in other militaries worldwide ranged from 2% to 17% of troops who participated in combat.
A casual observation of the prevalence of US veteran addiction, homelessness and suicide indicates a severe problem. When it is understood that often these issues are connected with PTSD and it is further understood that the statistics are not the same everywhere – in other words: it doesn’t have to be this way – it becomes all the more imperative to understand what makes IDF soldiers different.
Today, with the rise in terrorism worldwide, there is added impetus to understand PTSD. While one might be more likely to discover PTSD in soldiers, security forces or rescue workers, anyone who has been exposed to highly traumatic situations (such as a terror attack) could also be afflicted with PTSD. Just ask the people who worked next to the Twin Towers, the children of Beslan, the Bastille Day revelers in Nice, or any Israeli citizen.
To be able to deal with PTSD, one must first understand what it is
Post-Traumatic Stress Disorder or PTSD is a term that many have heard and few seem to truly understand.
Historically, a percentage of soldiers that went to war developed odd seeming behaviors which were not initially understood by those who remained behind. Some WW1 soldiers experienced panic, terror, or flight, an inability to reason, sleep, walk or talk and were diagnosed with “shell shock.” In WW2 similar symptoms were called “combat stress reaction.” Soldiers of the Vietnam War were said to have “Post Traumatic Stress Disorder.”
What all the soldiers had in common was that, contrary to apparent logic, removal from the field of combat did not relieve the symptoms.
Movies about the experiences of soldiers during and after the Vietnam War brought PTSD to public awareness but did little to create understanding or educate people on how to cope with the disorder.
One of the major challenges in understanding PTSD is the fact that most soldiers do not develop the disorder. Since soldiers who have seen combat have similar experiences, and most can readapt to civilian life relatively smoothly, many assumed that the small percentage that was unable to do so were flawed in some way and even attributed their symptoms to cowardice.
Reading American literature on PTSD shines light on why so many people find the condition confusing. The research is varied and results are often conflicting. Much of the material consists of long lists of possible symptoms and hypotheses regarding what types of physical/biological conditions might lead to a predisposition towards the disorder.
The material raises more questions than it gives answers, most significantly, why are only some of the people exposed to trauma afflicted?
It seems that much of the research was done with the goal of finding medication that could solve the problem. This suggests a number of assumptions:
- There is something psychologically flawed in the person suffering from PTSD.
- The problem is caused by or has created a chemical imbalance that can be controlled by external methods (drugs) to solve or at least control the situation.
- There is a potential for profit: purchase the right solution and the patient can be cured.
In contrast, the Hebrew literature on PTSD is clear and concise. For example, this explanation is from Israel’s National Trauma Center for Victims of Terrorism and War:
When exposed to a traumatic event, the emotional/psychological system is flooded with more stimuli than it can contain and process. The stimuli remain in the system, in their raw, unprocessed state and occasionally return, forcing their way into the person’s awareness in their original form. As a result, the sufferer re-experiences the traumatic situation, as a physical or emotional experience, exactly as if it were occurring all over again. Images, memories, noises and odors that were part of the original traumatic experience return, in an overwhelming manner that feels like an assault. Since this intrusive, uncontrollable experience is in and of itself traumatic, victims make an effort to avoid anything that might remind them of the traumatic event, creating a cycle of the intrusion and avoidance. This cycle is the heart of Post-Traumatic Stress Disorder (P.T.S.D.).
It is interesting to note that the word used in the Hebrew text which was translated as “the emotional/psychological system” actually means the system of the “soul”. In Israel, health-related issues are divided into those relating to the physical body and those relating to the soul. Those that desire to do so can interpret the term “soul” as an emotional system or as a psychological system but no matter how this is interpreted, it is understood that there are issues that are physical and issues that are intangible i.e. of the soul.
This not a matter of simple terminology, this is a fundamental difference in medical approach that influences both understanding and treatment. How can you heal damage to your soul (or emotions) by fixing a flaw in your physiology? This would be like trying to fill your car’s empty gas tank by changing a tire.
The symptoms of Post Trauma are a normal reaction to an unnatural situation
It is important to understand that PTSD does not indicate weakness, a flaw in character, moral fiber or temperament.
The symptoms of PTSD are emotional and physical sensations that then become exacerbated due to behaviors that are the result of the intrusion–avoidance cycle.
Comprehending the burden of intrusive traumatic events is difficult for anyone who has not themselves had the experience. Probably most people would picture the types of flashback scenes they saw in movies: the soldier, back in civilian life, hears a loud noise, a car back-firing or a door slam and suddenly has a flashback to being shot at on the battlefield or having bombs exploding next to him. While cinematographic constructs of flashbacks are dramatic they are actually poor explanations of what is actually being experienced. The intrusive memory is not a flash-back but more like a flash-now. Something in the present triggers the memory of the experience of the event with all of its physical and emotional sensations. The person is not transported back to their memory, rather the event is recreated and relived in the present.
“Burning chicken smells exactly the same as soldiers burning in a tank.”
One day I was cooking chicken. Distracted, I accidentally let it burn. My husband had an extreme, disproportionate reaction I found utterly incomprehensible. I thought to myself, “Why is he so upset? Only part of it burned, it isn’t ruined and anyway it’s just food…” Seeing I didn’t understand, he took a breath and told me: “Burning chicken smells exactly the same as soldiers burning in a tank.” He walked out of the room and I didn’t ask any more questions. I have made sure to never let chicken burn since.
Imagine being in your living room, waiting for dinner to be ready. Nothing can be more banal. Suddenly a smell triggers the memory of soldiers being burned alive in a tank. Many soldiers have had this experience and can recall the smell. Only some of these soldiers have PTSD that manifests in intrusive memories of the event. What’s the difference?
Standard memory: the person will recognize that the smell they smell today is like what they smelled as a soldier, on the battlefield. This may bring up other upsetting details of the event and yet the person remains in control of their memory. They are in the here and now and are recalling something that happened in the past. They are looking at their memory, not reliving it.
PTSD intrusive memory: the smell triggers the memory and suddenly the burning tank will be in the living-room, the feelings of that event will wash over him in an uncontrollable manner. He isn’t recalling the event, he is re-experiencing it now, in the present.
Intrusive symptoms can include an all-sensory or partial sensory re-experience of the traumatic event. Often senses that one is not entirely aware of at the time take a powerful role in the sense-memory (such as smell or sound). The sense of danger that overwhelmed the person at the time, overwhelms them again and they might feel panic, an urge to flee and can experience a feeling of fury at themselves or others.
These uncontrollable feelings are upsetting. Not knowing what might trigger them causes an underlying, constant, stress making it hard to concentrate and function normally. Fear of the experiences resurfacing in dreams or nightmares can cause insomnia which can then lead to physical health issues.
Often, the victim does not understand what is happening which, in turn, increases the feeling of helplessness and intensifying the suffering.
The intrusive traumatic memories are so unpleasant that the person suffering from them instinctively takes steps to avoid them. This can manifest in a wide variety of ways including:
- Efforts not to think, feel or talk about the traumatic event.
- Avoiding places, activities and people who might trigger memories of the traumatic event.
- Memory suppression of the event which leads to difficulty remembering details of the experience even when this is desired (this can be an issue with victims of a violent crime who need to testify in a courtroom).
I once heard a US Marine who fought in the Battle of Fallujah explain that he felt “quenched” like a steel sword that had been heated up and cooled down in order to be forged into the sharp Marine he was trained to be. He felt that this had turned off his emotions, making their expression next to impossible. This is an interesting description, particularly as this soldier also suffered from PTSD and it is actually fear of re-living the traumatic experience that causes many people experiencing the disorder to shut down their emotions. Knowing that the traumatic experience can suddenly resurface but not knowing when this might happen causes extreme stress (hyper-arousal). This leads many people to become irritable, impatient, defensive and prone to angry outbursts. Others begin to avoid all emotions. These people find it difficult to feel warm emotions, even towards those they love and they begin to find it impossible to enjoy activities that previously brought them joy (a strong emotion).
Avoidance may serve the victim well in the short run, creating the illusion of control over the problem, but in the long-run avoidance becomes a fixation and significantly damages the quality life. Over time, continuous use of avoidance as a coping mechanism can actually exacerbate the problem. The desire to avoid in itself is evidence that the intrusive element of the trauma is still present and will, sooner or later, return in the form of intrusive symptoms.
Who is susceptible to PTSD?
My experience with people traumatized by war and terrorism has revealed a pattern indicating who is susceptible to PTSD. Although much stigma has been attached to PTSD it is important to note that it has nothing to do with cowardice or any type of flaw in personality. In fact, the opposite is true.
The people that are more susceptible to PTSD are the ones that are more sensitive, the people that are capable of imagining: “What if.” These are the people that imagine, “what if I had been the one who was shot?” wondering to themselves, why it wasn’t them. Very often these are the most heroic people. They are the soldiers who, with their ingenuity and courage, in addition to saving themselves, succeed in pulling two friends out of a burning tank and later berate themselves for being unable to save the third soldier who remained behind. They are the ones that hold themselves up to impossible standards, who have the highest levels of compassion and are willing to sacrifice the most for others.
These people are not less courageous; they are more courageous. The intrusive traumatic memories they experience often lead them to think poorly of themselves, be angry at themselves for being fearful but true courage is not lack of fear but the ability to feel fear and do what is necessary despite the fear. People suffering from PTSD die a thousand deaths, experience a thousand traumas. Being able to endure this and continue to do other activities is nothing short of astounding.
What makes Israeli soldiers different?
Israeli soldiers aren’t different. It is Israel itself that is different.
Unlike in the US, there is no person in Israel who is untouched by terrorism or war; soldiers are an integral part of Israeli society.
The IDF is a citizens’ army, consisting of our fathers, brothers, husbands, friends, sisters and daughters. Almost every household has a soldier, if not a number of soldiers, many of whom have fought in multiple wars. Those who don’t have a soldier in their own family live next to a household with a soldier. Virtually every person does reserve duty and /or has colleagues who take leave from work to go to reserve duty. Israelis pass soldiers on the bus, in the train and in the store. Even those portions of society that do not enlist (such as Orthodox Jews) have seen soldiers and had interactions with soldiers. This means that many Israelis who have not themselves been on a battlefield have secondary experience with those that have – they have dealt with injuries and death of friends and family, brothers and sisters.
The prevalence of terrorism means that there is little separation between the soldier on the battlefield and the mother in her home, the child walking to school or the father driving to work. Many Israeli civilians have found themselves under attack by terrorists with rocks, knives, guns and suicide bombs. Others have witnessed attacks or seen their aftermath. Others are related or connected with those who have been in these situations.
The average Israeli knows or can imagine what a soldier or a victim of terrorism has experienced. Personal experience creates understanding and compassion for the pain of others.
Israel’s current generation of 40-60 year-olds grew up with Holocaust survivors. They didn’t understand the survivors or their sometimes-strange behaviors. Some survivors picked up half-eaten sandwiches that other people had thrown away and put them in their pockets, just in case. Others were terrified of dogs. Some clung to their children. Others almost never touched their children. Some were perfectly normal in the day but screamed in their sleep.
It took many years for people to understand that these behaviors developed as a result of the extreme trauma the survivors had experienced. Later on, it was discovered that trauma could be passed on – that the second generation, the children of the survivors had developed their own form of trauma related behaviors.
The average Israeli knows that terrible experiences alter the psyche and affect behavior.
“What doesn’t kill you, makes you stronger.”
Israelis have developed an attitude of “What doesn’t kill you, makes you stronger.” Although this expression is often said jokingly, regarding small uncomfortable situations like going to the dentist or telling a child to do something they don’t like, it is indicative of a societal mindset. Israeli’s experiences as individuals and as a nation have taught that terrible things will happen. Some people will die as a result but those who survive will be stronger because of it. This is the mindset of resilience.
“Maybe it’s because of something he experienced.”
A lawyer I once met was obviously brilliant but also obsessive and prone to temperamental fits. I was told about him: “Oh yeah, he’s nuts. But maybe it’s because of something he went through [as a soldier]”. In a single breath, there was a swift judgment, forgiveness and understanding.
Generally, Israeli society is willing to give people the benefit of the doubt and forgive unpleasant behaviors if and when they are a result of previously experienced trauma.
It’s different when you are fighting for your home
One of the reasons traumatic events can be scarring is that they often seem completely random, creating a feeling of helplessness. The soldier may question why his friend was killed and not him, after all, seconds before, he was standing exactly where his friends stood when the bomb exploded. The person riding the earlier bus might question why she left the house earlier that day and wasn’t on the bus that was blown up in the terror attack – the bus she normally rode to work. The lack of control over traumatic events that occurred or could occur in the future is frightening. In Israel, this is tempered with a collective purpose. Everyone goes to the army for the same reason. Everyone suffers from terror attacks for the same reason. The individual cannot control what is happening but at least they know why it’s happening.
While Americans might honor or respect their soldiers, Israelis love their soldiers passionately. Honor is something you do from far away. Love is up close and personal. To Israelis soldiers aren’t heroic figures you throw parades for and give medals. Soldiers are our boys, our girls, our family. You feed them, make sure they are warm and comfortable. You let them sleep on your shoulder if they fall asleep next to you on the bus. It doesn’t matter if you never saw them before and don’t know their name. It doesn’t matter if they come from a different background than you or have a personality you don’t like. The minute they put on the uniform they belong to you and you belong to them. Each soldier could be anyone’s soldier so you do for someone else’s son or daughter exactly what you would hope someone would do for yours. Our heroes are soldiers that go home and their mother tells them to take out the trash. No one calls them “Sir.” Rarely will anyone thank them for their service but everyone will love them.
When it is understood that PTSD is not a physiological problem but a type of emotional poison that overloads the soul / psyche effective measures can be taken to both prevent and treat those that are suffering.
Drugs may numb symptoms like anxiety or insomnia but they cannot heal the symptoms because they don’t address the cause of the problem.
The greatest need for someone suffering from PTSD is to be understood and then to find an outlet for their emotions. For this reason, many of the beneficial support programs developed combine work with animals (who do not demand explanations and don’t judge) or non-verbal activities that create a peaceful place for the soul / psyche such as art therapy or physical activity in nature. One of the most powerful ways to regain the feeling of control that PTSD steals from the victim is to empower them to mentor others. Who better to teach that every one of us has the choice to be a survivor, not a victim?