Given all that this country has faced, it's not surprising that nearly one in 10 Israelis currently suffers from post-traumatic stress disorder (PTSD). With its past still shadowed by persecution, nuclear capabilities in the hands of neighboring dictators and other existential threats, periodic wars, terrorism, military reserve duty, the strains of immigration, road accidents, personal tragedies and illnesses, it's surprising that the Israeli rate isn't even higher.
The Israel Center for the Treatment of Psychotrauma (ICTP), established in Jerusalem 20 years ago by Herzog Hospital, has had its hands full ever since with the growing phenomenon of psychotrauma and - headed by clinical psychologist Dr. Danny Brom - is a world-recognized innovator in its research and training of professionals to deal with emotional trauma.
Thus it was natural for the ICTP to initiate a two-day International Conference on Trauma in Early Childhood, attended at the end of June on the Hebrew University of Jerusalem's Mount Scopus by some 300 experts from Israel and abroad. It was organized in cooperation with the HU's Paul Baerwald School of Social Work and the Jewish Family and Children's Services of San Francisco. After the conference ended, many participants went on a tour of Sderot, the development down that has suffered thousands of rockets from Gaza, and visited ICTP projects in day-care centers.
The title of the conference focused on babies and pre-school survivors of psychotrauma, but the lectures gave a wealth of information about the influence on their parents - especially their mothers - and how they cope.
THE TERM "trauma" comes from the Greek word for "wound," but it has in recent decades been used to describe damage to the psyche as well. "There has been growing awareness of the fact that people exposed to events such as terrorist attacks or car accidents are often not only physically injured, but mentally hurt as well," says Brom. Other examples of traumatic events are natural disasters, sexual assault or serious disease.
PTSD can occur when victims - or their loved ones or even strangers - are exposed to the threat of death or serious injury and develop a strong feeling of fear and helplessness. As the event could not have been predicted or prevented, it may shatter one's sense of security and leave the victim feeling vulnerable. Victims should not regard themselves as "crazy" or abnormal, as PTSD is a normal response to a not-normal event.
For example, if an individual suffers only minor physical injuries in a major car crash that killed relatives or friends, he may start having nightmares about it. He may jump at the sound of a siren or the sight of an ambulance. He may avoid even going near the site of the accident.
Untreated, long-term symptoms include intrusive and upsetting memories; flashbacks in which survivors feel or even act as if the incident is recurring); feelings of intense distress when reminded of the trauma; intense physical complaints such as headache, stomach ache or chest pain; loss of interest in life; feeling emotionally numb; difficulty falling or staying asleep; irritability or outbursts of anger; concentration problems; excessive alertness, as if the event will repeat itself; a feeling of guilt; depression; suicidal thoughts; alienation; and feelings of betrayal and distrust.
BROM NOTES that the majority of people exposed to a traumatic event - while developing some immediate symptoms - will fully recover from PTSD without treatment. Anywhere between two percent and 49% of survivors may develop the disorder. A gene that makes it more likely for a victim to develop PTSD was discovered seven years ago at the psychiatry department of Hadassah University Medical Center in Jerusalem.
But it was made clear at the conference - which devoted much time to the effects of rockets, missiles and terrorist attacks on Israelis in the north and the south - that psychologists, social workers, physicians and teachers trained in PTSD can make the symptoms dissipate. They help victims "process" the memories using one-on-one, family or group therapy, cognitive behavioral therapy, medication, support groups and even EMDR (eye movement desensitization and reprocessing). Brom and colleagues noted that the sooner PTSD victims are treated, the better, and it is believed that there is a "window" of opportunity for optimal treatment.
THE ICTP set up its Metiv center in Jerusalem's Kiryat Hayovel quarter to provide walk-in treatment to PTSD victims who refer themselves for care. They are taught to develop coping mechanisms to deal with the fallout of traumatic events. Its "Resilience Unit" was established to provide resources for the professional and lay public.
Since 2002, it has provided resilience building for 4,000 teachers and early childhood educators, and specialized training for school counselors and psychologists. The ICTP has also counselled "first responders" working in Magen David Adom, Israel Police and Fire Service on coping with the high levels of trauma they experience in their work.
Dr. Ruth Pat-Horenczyk, a clinical psychologist and at ICTP's research director, reported in her lecture on the second day that she and colleagues have spent years comparing PTSD in children living in Sderot and Shaar Hanegev within firing distance from Gaza, with those in Haifa and Kiryat Shmona, which suffered direct hits during the Second War in Lebanon. The first two locations were victims of chronic exposure to fire, while in the other two, the firing was acute during the war (although an older generation in Kiryat Shmona were shot at in previous decades). A total of 415 young children in 317 families were interviewed. After studying Sderot children for three years, the team followed them up three years later and found a "significant deterioration in the clinical picture in 60% of the families," Pat-Horenczyk said.
Children suddenly started wetting their beds and started asking for a baby pacifier they had outgrown. Children refused to sleep alone, had trouble falling asleep and had bouts of crying. Mothers said they felt like babies and wanted their child to be adults and adopt mothering behavior. Some mothers (it was much more difficult to get Sderot fathers to participate) intentionally woke up their young children just to get their support.The team found that those who had previously been exposed to traumatic events suffered much more from PTSD after rocket attacks, and their symptoms were more severe than those who had been exposed to only a new event.
Fully 88% of Sderot children had been exposed to more than one rocket attack. Pat-Horenczyk reported that they diagnosed PTSD symptoms in a huge 41% of Sderot mothers interviewed and 33% of the fathers. By comparison, the rates were "only" 15% in Haifa and about the same in Kiryat Shmona after the Second Lebanon War.
ON THE first day of the conference, Prof. Alicia Lieberman of the psychiatry department at the University of California at San Francisco declared that even babies "remember traumatic events in their bodies" with increases in stress hormones such as cortisol. Many professionals and parents have dismissed this idea because infants and young toddlers do not have the verbal ability to describe trauma, but it nevertheless is stored in their brains, she asserted.
Lieberman, who was born in Paraguay and earned a bachelor's degree at HU, explained that the seat of verbalization is in the cortex, but the visceral responses to trauma are based elsewhere. Nevertheless, people are wrong to assume that when traumatized infants grow up and don't speak about it, they weren't influenced by it. Therapists often start their relationship with traumatized parents and children with the mistaken idea that if a child did not discuss it, they should not bring it up, she said.
Dr. Ruth Feldman of the psychology department at Bar-Ilan University's Gonda Brain Center and head of the early development lab added that because psychological and physical development is very rapid in babies and toddlers, the "arrest of development" caused by a traumatic event would be significant. Her study was based on intensive observation of the children with their mothers and in preschools. "Suddenly, children began to speak in shorter, simpler sentences and showed less imagination in play, less symbolizatoin, poorer peer relationships, less initiative and poorer socialization than before. Some even began to hit or bite other preschoolers" as a result of their experiences.
Families with multiple risks, such as a single parent who is unemployed, have a much higher risk of PTSD symptoms than others with more support.
Prof. Claude Chemtob, director of the child and family resilience program of psychiatry and pediatrics at Manhattan's Mount Sinai School of Medicine, is a frequent visitor to Israel and has done studies on the effects of terrorism on children in Sderot and New York (children within walking distance of the World Trade Center when it was destroyed).
Chemtob - a Jew born in Egypt who lived in France and Hawaii before moving to NY, thus developing an intriguing accent - noted that his collaboration with counterparts in Israel has been very fruitful, as Israel is chronically exposed to trauma. In Manhattan, there was a "one-shot mentality" a year after the World Trade Center disaster, as the authorities thought that a year later anybody who needed help had been treated. "The teachers and school counsellors didn't get training, and principals didn't see them as offering help," Chemtob said. Of 6,000 kids he and colleagues screened, 400 were treated for PTSD. Half were given group treatment and half individual, but both techniques were equally effective.
It was not easy identifying those with negative reactions to the terror attack, said Chemtob, as many didn't complain to their parents because they "didn't want to worry them." Generally, preschoolers affected by traumatic events are "the last to get treated. Only 9% of state money was spent on younger children and less than 1% on those below five."
True recovery from a post-traumatic event, concluded Chemtob, happens "only when the victim discovers 'a gift' in the horror, when he reaches the conclusion that he is a better person in some way as a result of it."