Trauma: the unreported casualty of war

http://therapytoday.net/article/show/449/

In January, during the Israeli military incursion into Gaza which followed continuous shelling of Sderot and the Western Negev from Gaza, a BBC correspondent stood on a lookout point where she could see both Sderot and Gaza, and reported that more than 1,000 people had been killed in Gaza, while 13 people had been killed in Sderot and the Western Negev. ‘The numbers speak for themselves,’ she said.

If this were a sporting event tabulating the number of fatalities on each side, the BBC reporter would have a point. However, while newscasts from southern Israel do report the torrent of missiles from Gaza, these soundbites are often followed by a laconic news announcement of ‘No damage and injuries’, suggesting that there is no news story of any human interest for the public to be concerned about.

Nothing to be concerned about? In a story that has repeated itself hundreds of times, a shaken Sderot woman who had witnessed a missile explode in her yard and miss her home and family by a few metres, stared with disbelief at a reporter who congratulated her that she had suffered ‘No damage and injuries’. Looking at the reporter, with her whole body quivering uncontrollably, she said to her that ‘It’s easier to photograph blood than to photograph the soul’.

Indeed, in a world of fast-moving images on the screen and even on the net, it is nearly impossible to portray this woman’s psychological situation. The sight of blood is easier to report than an entire population living in fear and helplessness, with no ordinary life. Shrapnel injures the body; the body receives treatments and heals. The mental issue is more complicated to relate.

Indeed, the attacks from Gaza on southern Israel are not necessarily waged to inflict fatalities. These attacks, described in military jargon as ‘low intensity conflict’, destabilise the other side, and instil fear into the daily lives of the people. So when a siren goes off to warn of an incoming missile, an entire population knows that it has 15 seconds to scamper for shelter. Israel’s southern region has endured more than 12,000 mortar, Kassam and Grad missile attacks over a period of eight years. That means that on 12,000 occasions, an entire population has run for cover.

Post-traumatic effects

In a recent study conducted by Natal (Israel Trauma Center for Victims of Terror and War), researchers discovered that close to 56 per cent of Sderot residents have suffered in some way from Palestinian rocket attacks. According to a report presented by Natal Community Staff Director, Dr Roni Berger in Beersheva on November 24, nearly half of Sderot’s population has been either physically or emotionally damaged by Palestinian rocket fire. Over 4,000 Sderot residents now suffer from symptoms of post-traumatic stress disorder (PTSD), while one third of Sderot teenagers aged 13 to 18, have been diagnosed with trauma-related learning disorders.

As readers of this journal will know, PTSD is a severe and ongoing reaction to a terrifying ordeal that involves physical harm or the threat of physical harm to the person, according to The National Institute for Mental Health. People who develop PTSD may have witnessed a loved one who was harmed in a traumatic event or were victims themselves. Symptoms of PTSD usually begin three months after the ordeal but can also emerge years afterwards. Some people can recover within six months while others have symptoms that last for much longer. For some people, the condition becomes chronic. ‘The initial symptoms of shock include an accelerated heart rate, dry mouth, limbs falling asleep, a sense of fainting, or seeming paralysed or emotionally detached,’ says Professor Gabi Schreiber, Chief of Psychiatry at Ashkelon’s Barzilai hospital.

Dr Adrianna Katz, head of the Sderot Mental Health Center, says that the shock impacts the victim’s ability to function for months after experiencing a Palestinian rocket explosion. ‘Many rocket terror victims suffer from depression, sleepless nights, severe anxiety, and have trouble going back to a regular routine,’ she says. The Natal study showed that almost 50 per cent of Sderot residents know someone who has been killed in a Palestinian rocket attack, while 65 per cent personally know someone wounded in an attack. Over 90 per cent of Sderot residents have experienced a Palestinian Kassam explosion at some point – whether it be in a neighbourhood, home, school, business or other residential setting.

Dr Mina Zemach and the Dahaf Polling Institute conducted the research in order to compare Sderot to other communities who live outside of Palestinian missile range. Sderot residents made up the test group, while residents of Ofakim, a town of similar socio-economic make-up to Sderot but not under rocket attack, served as the control group. The study revealed that three times as many Sderot residents had gone to a spiritual counsellor (such as a rabbi), and a family doctor than did Ofakim residents.

Dr Berger explains that there were several reasons why Sderot residents suffered from higher degrees of trauma than residents of other Israeli communities within rocket range. ‘The fortifications in Sderot are poorer, and the population is weaker as well. The social unity is smaller. It’s a population who felt, and still feels, abandoned,’ he says. In addition, 45 per cent of the shells fired from the Gaza Strip target Sderot according to IDF (Israeli Defense Forces) intelligence.

Although adults in Sderot showed significantly higher levels of trauma and stress in the study than adults living in other Gaza vicinity communities, children of Gaza vicinity communities did not fare so differently from Sderot children. Close to 75 per cent of children aged 12 to 14 living in Gaza vicinity communities, suffer from symptoms of PTSD compared to 86.6 per cent of Sderot children. ‘Only a minority of those suffering from PTSD actually seek help,’ Dr Berger says.

The Impact of Palestinian rocket terror on Israeli children

Periodically schools in Sderot and the Western Negev have been forced to close during periods of intensive rocket attacks. According to research done by Sderot’s Resilience Center, a treatment centre that offers support and counselling to Sderot residents during times of emergency, there is a major problem manifesting itself in young Sderot children.

Clinical psychologists working at the centre discovered that many Sderot children are not developing speaking skills at a rate appropriate to their age. A normal child learns to speak around the age of one. But many children in Sderot have not begun to speak by the age of three or even four. Those who are capable of speaking, stutter and cannot complete words. Dr Dalia Yosef, Director of the Sderot Resilience Center, explains that the constant rocket fire upon Sderot has created a state of stress and panic that has dramatically impacted the development of young Sderot children. Dr Yosef and the clinical psychologists who work with her, counsel Sderot children from the ages of one to 18, offering treatment for a wide variety of issues.

‘It is important to note,’ says Dr Yosef, ‘that these Sderot children have been born into a reality of constant rocket fire. The world, as it appears to them, is unsafe and scary, full of insecurity and chaos. Their sense of security has been shattered by the continuous attacks. These children develop symptoms of PTSD early on, suffering from sleeping disorders, nightmares and anxiety attacks. Many experience regression, going back to wetting their beds.’

Those children whose parents suffer from signs of PTSD have even more complicated issues. According to Dr Yosef, children of parents diagnosed with PTSD sense that their parents cannot protect them. ‘These kids’ problems are even more severe than kids whose parents are more psychologically stable,’ says Dr Yosef, who explains that a young child hears the rapid breathing of his parent, when the Tzeva Adom (the early warning radar system) sounds and understands that his parent is frightened. ‘Once the child understands this, then he perceives that the world is unsafe and that his parent is unable to properly protect him,’ she adds. ‘The parent feels threatened and so does the child. Later on, this feeling of insecurity and stress affects the child in areas like speech, hindering normal speech development.’

Younger children go back to the bottle, to the pacifier, and have extreme difficulty separating from the parents. ‘Kids are scared to go to the bathroom or to the shower by themselves, because of the fear of a rocket strike,’ says Dr Yosef. ‘The situation has created unhealthy relationships within the family unit.’ Children as old as 12 sleep with their parents. ‘Even during ceasefire days where missiles don’t fall on Sderot, the trauma and stress continue because people continue to anticipate rocket attacks. Only a permanent long-term quiet will help these children and their parents recover,’ says Dr Yosef. ‘The moment there is a siren alert and a rocket explosion, all the progress we have made in the treatment is destroyed.’

Livnat Shaubi, a lifelong resident of Sderot and the oldest in a family of 11 children, relates how she spent an entire day with her younger siblings, helping them find ways to cope with the school closures during the heavy shellings on southern Israel. After spending four days at home, exhausting Lego, board games, and playing balls, the Shaubi boys – Hananel, David and Yehuda, ages 5, 7 and 11, respectively – created Kassam rockets from plastic bottles they found lying in the house. ‘Like other Sderot kids, my mom cannot allow my younger siblings to play outside during these periods of rocket attacks,’ Shaubi says. ‘We stay inside in the bomb shelter, but my brothers are desperate for things to do.’ Shaubi says that the first words her five year-old brother Hananel learned to say, along with Daddy and Mommy, were ‘Tzeva Adom’.

Mental Health Centre overwhelmed

Even when the fire from Gaza significantly decreases, Sderot and Western Negev residents still reel from the impact of the war. The Director of the Sderot Mental Health Center, Dr Adrianna Katz, told Sderot Media Center how area residents are streaming into her clinic, seeking therapy for developing ‘post-war’ trauma symptoms.

‘Many new Sderot patients are coming in for help, even though they have lived with the rocket terror for eight years now,’ says Dr Katz. ‘PTSD symptoms among area residents emerge during periods of “quiet” like now. Many seeking therapy had tried unsuccessfully on their own to suppress these symptoms of trauma during the past rocket escalations.’

Many more do not seek help. People with PTSD often avoid stimuli associated with their trauma. In Sderot, it is often impossible for residents to escape the reality that has brought on the trauma symptoms because of the fragile quiet. Dr Katz explains that recovering patients who hear the Tzeva Adom siren just once – the alarm that sends civilians fleeing to shelters – will go back to experiencing PTSD symptoms.

‘During the war, my staff discovered a new type of anxiety that developed among Sderot residents, which we termed “optimistic anxiety”,’ says Dr Katz. ‘Although residents were fearful of the rocket fire, they also experienced for the first time in years a sense of optimism that the operation would completely end the rocket terror. However, Sderot residents do not believe that the operation brought about a complete nor lasting change as it was finished halfway. In fact, because the rocket attacks have spread as far as Netivot, Ashdod, and Be’er Sheba, Sderot residents feel even less secure. Many families left Sderot during the war and travelled to nearby cities which they believed were safe from rocket attacks, only to find out they were not. This fact, which was revealed during the war, has spurred further anxiety among patients.’

Over 5, 500 patient files have been opened in the Sderot Mental Health Center, which has a staff of four counsellors, since Palestinian rocket fire on the city began in 2002. Out of those files, 2,500 are active, with many patients seeking treatment for the long-term, says Dr Katz. She does not have an exact number on how many new patients have come in for treatment since the war.

Dr Katz believes that there are many more PTSD victims in Sderot who are not seeking help. Most residents who do come to Dr Katz are referred by a doctor or medical expert, while a few arrive of their own initiative. She offers a small smile when I ask her if she has any hope for a lasting peace in the region. ‘Not at this moment,’ she says, as she gets ready to greet her next patient.

‘Optimistic anxiety’

During the heaviest fighting of the Gaza war in January, when Israel’s southern region absorbed as many as 50 attacks a day, Dr Katz noted that patients coming for treatment for shock were actually less anxious and traumatised than at other times. ‘For the first time, the residents felt that someone cares about them and provides them with the protection they’ve been expecting for eight years.’ Dr Katz calls this ‘optimistic anxiety’, and explains that when the Israeli army responds to the ongoing missile fire, the residents have hope that they will see a light at the end of the tunnel, and a qualitative change in their life.

As this story went to press, the Sderot Mental Health Center collapsed under the financial strain of not being able to service almost 5,000 outpatients who suffer the effects of sustained shelling of their community. The future of this vital community service remains unclear. Updates on the situation in Sderot are available at www.SderotMedia.com .

To read a critique by Irwin J Mansdorf PhD of the article ‘Palestine: to resist is to exist’ by Martin Kemp and Eliana Pinto (published in the March 2009 issue of Therapy Today), see www.therapytoday.net

* David Bedein MSW is a community organisation mental health practitioner who directs The Center for Near East Policy Research in Jerusalem, Israel. He also advises the Sderot Information Center for The Western Negev in Sderot, Israel. With thanks to Noam Bedein and Anav Silverman from Sderot Media Center for assisting with the research for this article.