“IF A thermos flask falls on the floor and all the glass inside breaks, from the outside it still looks completely the same,” says Orly Gal, executive director of Natal, the Israel Trauma Center for Victims of Terror and War. “You can never know what people are suffering and going through. We call it 'the transparent injury' because you cannot see it, and it's often so hard for them to prove that they are suffering from post trauma.” Prior to taking on her role at Natal 10 years ago, Gal had been deputy IDF spokesperson for 25 years and had worked closely with a number of chiefs of staff. She succinctly sums up the challenge faced by so many Israelis in admitting to themselves and those around them that they suffer from PTSD (Post Traumatic Stress Disorder) and need professional help. “These individuals will forever pay the price of the Arab-Israeli conflict,” says Natal's website, “and it is up to us to extend a hand and help them overcome their tragedies.” One such tragedy took place in the heart of Tel Aviv on June 8, at the Max Brenner Café in the posh Sarona Market compound. What happened in the aftermath of the attack by Palestinian gunmen who killed four and wounded many more is an up-to-date case study on why Natal has become such a key Israeli outreach service. “The reaction was unusual because normally it takes days or weeks before people realize what they are going through,” Gal tells The Jerusalem Report. “The event took place at around 9 p.m. By 9:30 there were already calls, and by 10 we had already begun interventions in the field. “The helpline received 74 phone calls from the area of the terrorist attack. The two restaurants ‒ Max Brenner and Benedict ‒ asked our professionals to help them with their teams. Taglit-Birthright Israel had a group here, and they asked us to come speak to the young people who had been in Tel Aviv at the time. One of our professionals went there immediately and answered their questions. Just imagine how many people we touched in just one terrorist attack.” Next year Natal will mark its 20th anniversary. Already more than 210,000 people ‒ yes, 210,000 people in a country of fewer than nine million ‒ have reached out for support and guidance from the organization that sprang from the vision of the late Dr. Yossi Hadar. The highly respected psychiatrist at Bar-Ilan University spotted the genuine need to help men, women and children traumatized by war and terrorism ‒ people who otherwise would have been left alone to overcome the horrors they had witnessed, work through awful images and experiences and likely descend into a vortex of depression and desperation. Hadar died in 1997, just a month after the project was established, but Natal has long since become the “go to” address for Israelis – be they Jewish, Muslim, or Christian – who need someone they can trust and who understands them in what can often be their darkest hour. These days, the charitable organization has no fewer than 120 psychologists and social workers across the country ת who can be called upon at a moment's notice to aid traumatized persons of all ages. They work with individuals, family health clinics, and municipalities, constantly reviewing and reevaluating their methods and practices to be sure they offer the best possible help. Natal's crucial role in picking up the pieces of lives that might otherwise have been completely ruined is a model that is proving to be of increasing interest to decision- makers and first responders from many countries around the globe, who are now facing the growing specter of radical Islamic terrorism in their midst. In the US, Natal has overseen the establishment of a telephone helpline for the Wounded Warrior Project (WWP), which takes care of veterans from Iraq and Afghanistan. And even before the recent spate of lethal violence on the streets of the US directed against police officers sparked by the killings of African-American men, Natal was already sharing its knowledge and experience with community leaders in Chicago, the scene of some of the country's worst black-on-black gang warfare and street violence. I visited the organization's trauma center on Ibn Gvirol Street in central Tel Aviv, not far from Rabin Square and a short walk from the site of the Sarona attack ‒ a building purchased and renovated by philanthropist Judith Yovel Recanati, a friend of Hadar, who also covers the organization's annual overhead. The other 72 percent of Natal's 17.2 million shekel annual 2016 costs are funded by donations. In a recently published report presented to the Knesset, Prof. Gabi Bin-Nun, formerly deputy director general for health economics and health insurance at the Health Ministry, noted that the 15m. shekels Natal spent in 2014 on its work was worth at least 75m. shekels in savings to the state on medication, national insurance and in people functioning normally and continuing to pay taxes and making other contributions to the country. Yet, the government currently contributes just 360,000 shekels a year, or 2 percent of Natal's budget. “This is a trauma center that people come from all over the world to see,” Gal explains. “It's a historic building that housed the Defense Ministry for 50 years. In the Yom Kippur War, a lot of wounded soldiers, families of POWs, and bereaved relatives would come to this building. We always say that we wish the walls could speak. Judith bought and renovated it, and gave it to Natal to use. It was a strategic moment in the life of Natal, and allowed us to change a lot of things and do things we'd only dreamed about.” They began with low-level media promotion, but not many people came. Similar, it would seem, to the original reluctance in Israel to allow Holocaust survivors to talk about their horrific experiences, there seemed to be a reluctance, even embarrassment, on the part of so many traumatized people to admit they were suffering. The Sabra Israeli, the tough guy image encouraged by compulsory military service, meant there was a stigma attached to admitting you needed help. Tens of thousands of people were often barely functioning in their day-to-day lives and were fearful of anyone recognizing their frailties. Their families and friends were suffering, too. Then the intifada began in 2000, and slowly people started to seek help. “IN NATAL, we don't have bureaucracy, so they don't wait,' says Gal. 'All they want is to come here and come back to life. They don't want money. They want to go back to university, to having a wife or husband ‒ because now it's 50/50 [men and women] ‒ and we have so many kids suffering in the south [as a result of the Gaza wars and ongoing tensions]. People come here because they really want to get treatment, get back to living and shalom aleichem. “At least 20,000 to 22,000 people a year now come to Natal, a number that has seen a sharp rise due to the ongoing terror situation. Jews and Arabs, little children to old people, [military] veterans and special needs, all strands of Israeli society come not just to the Tel Aviv center, but to Natal across the country.” I ask Gal, is it not the job of the state to take care of its traumatized citizens? “Yes,” she agrees, “but we're not instead of the state. We help the ones that decide they don't want to go to the state for help. There are a few reasons why they come to us. One is that they blame the army. They say that the army sent them to fight in the war and because of this they got PTSD. They don't want to deal with bureaucracy and prove what they're going through. They want something completely independent. “Second, [treatment at Natal] will not be written in their file. A lot of them are very worried that if they are known to have been treated for PTSD it might prejudice their job prospects, personal relationships and more. A lot of people are falling between the cracks and we take care of the whole circle surrounding the person because their whole life changes when the trauma happens.” Gal recalls the many occasions when wives shared their experiences of being threatened by traumatized husbands who wake from nightmares and become violent. Wives, husbands, children, parents, all feel the knock-on effect of a close family member with PTSD. “Natal provides a tailor-made service offering different things ‒ one-on-one treatment, or as a couple, or a family. It can also include art therapy, movement therapy, so many things. They can choose whatever combination suits them. This tailor-made service is the best option for every person. We will not push them.” Yardena Dafni's son, Amit, was severely injured as a result of a road accident while serving in the IDF in 2008. She and her family went through the initial shock of learning of the accident and then the long road of Amit's recovery. Dafni, from Givat Ze'ev near Jerusalem, received some psychological help from Health Ministry professionals in the aftermath of her son's accident, but she soon understood she needed something more. “I heard that Natal held a group meeting for mothers of wounded soldiers and they invited me to come,” she tells The Jerusalem Report. “From the very first time I went it was amazing. They give the most wonderful emotional support possible. I was in a group of mothers of soldiers wounded in wars and many other ways, but some people prefer to receive individual treatment. “First, they make you understand that you are not alone. Then there is the help that is offered whenever you need it ‒ they simply opened their door to me and everyone else. Among us were people in a very difficult place, but the support for one another, with phone calls, conversations, meetings with psychologists, and much more, was simply amazing. “WHEN A mother says she went to pieces when she saw her child in such a state in the hospital, we all understood. There is no need to explain. I was there for three years along with many others. There were days when we all cried and the trauma came back again and really hurt, but Natal has given us the strength to go on. “We haven't forgotten what we went through, but we are now able to move forward. Natal's support is extraordinary.” Apparently, I'm not alone in being amazed at the speed with which Israel reacts to terrorist incidents and the remarkably fast return to normal at the site of the attack ‒ often on the same day. I've often wondered if this might be counterproductive, not giving people a chance to mourn or come to terms with what has happened. Gila Sela, head of Natal's telephone helpline service – invariably the first contact trauma victims have with the organization – explained the reasons this method is employed in Israel. “This is a therapeutic method to expose people to the place because it's not rational to think there will be another attack in the same place the next day,” Sela says. “You want to expose people to the event because you don't want them to develop avoidance. If you say, 'I will never go to Sarona,' for example, you [by extension] might say I will never go to a mall, I will never go into the street, then you could find yourself staying in your room and this is the beginning of classic PTSD symptoms. You have to expose people to the place. “Not long ago, we had the bombing of bus no. 40 in Tel Aviv. We got many phone calls and many people started therapy here. What can you tell them? Don't go on bus no. 40? It's not realistic, but people do this to try to protect themselves. That's OK. That's the protection mechanism we have. But as a therapist you have to explain that [avoidance can lead to greater trauma]. “Now, you won't go on bus no. 40. Tomorrow, if you are in an anxiety zone, you will avoid all public buses, then all public transportation such as trains or planes. It will go deeper and deeper and snowball.” Listening carefully, surely like every other Israeli at some point having wrestled with a similar dilemma, Sela's explanation made a lot of sense. “We take [the trauma] when it is small. You don't want it to grow. We use a psycho-educational explanation, as when you explain to people all the elements, it makes a big difference. In general, when they are so traumatized, people need to be listened to and given the opportunity to vent their feelings. I'm not sure they understand their feelings at seeing the horror, the anxiety, the fear. Most people don't know how to deal with extreme things that happen. We explain that it's very normal to feel the way they do.” Sela outlined the three phases to trauma. First, the initial acute stress from the time the event occurs up to two days after during which some will become hysterical, others will freeze. Every reaction is OK, she says. The second is from 48 hours to one month after the event. During this period, again, she says, it is alright to feel the symptoms of avoidance, the fear, the sleeplessness. Over this period, she says approximately 80% will begin natural recovery ‒ returning to work, socializing with friends, generally feeling better and sleeping at night. The third phase affects some 20 percent whose symptoms do not dissipate after the first month. The trauma stays with them and sometimes it gets worse. When there is additional depression, Natal's counselors and clinicians see the need for intervention, which can include home visits, individual counseling, and sessions with psychologists and other professionals. Many of those requiring help are young soldiers in the aftermath of their compulsory military service, many of whom go traveling to remote parts of the world such as India or South America, with the intention of leaving their military or wartime experiences behind them when they take off from Ben-Gurion airport. According to Sela, though, when it comes to mental trauma, you can run, but you can't hide. “They go on their travels after the army and think they will leave behind the memories and the sights of war, but it runs after them. It haunts them ‒ the sights, the memories, sometimes the bodies. It catches them anywhere, and when they are away from home, away from their loved ones, it can be very difficult because they don't have the support they have here and sometimes feel very lonely,” she says. Some, she adds, contact them via text chat from places such as South America and India. “They don't understand what is happening to them. We still have many hundreds of calls from veterans of Operation Protective Edge [the 2014 Gaza war], who are seeking help. Some of them are very wounded. Many stop their studies because they can't concentrate. They have rage attacks that they can't explain to themselves. They say 'I don't know myself.' “One of the horrible things about PTSD is that you don't die from it, but it changes your personality. If you don't treat it, it eats you from the inside and you become weak.You become another person,” says Sela. Though the IDF tries to do the right thing by its soldiers, it still – judging by Natal's experience – isn't doing enough to mitigate the mental trauma inflicted on its soldiers, many of whom are just 18 or 19 years old. “I can tell you that for the last 10 years, from the Second Lebanon War through to Protective Edge, we had hundreds [of soldiers] here,” notes Gal. “Today, two years after Protective Edge, we know every day we will see new soldiers here. Look, the army does a lot of work, but maybe it's just not enough.” IN THE clinical department, there is a psycho- historical center established through a donation from Steven Spielberg, part of which was used to build a testimonial center. Gal says that former soldiers “come and tell their stories to the camera, and I can tell you it has changed a lot of lives. Some of them agree to allow parts of the testimonial to be made available to the public ‒ including some from the Second Lebanon War. Some have given a copy of their video testimony to their family, and suddenly the family says, 'Now we understand what is going on.'” Trauma is also present in the youngest members of Israeli society, especially in those living in the south within range of the rockets, which for years have emanated from Palestinian terrorist groups in the Hamas-run Gaza Strip. Many schoolchildren struggle to concentrate, and others from towns and villages close to Gaza have sleeping difficulties and suffer nightmares. Natal has designed educational programs for teachers to help the traumatized children. One of its projects is a new website called “Makom Batuach” [A Safe Place] for schools, kids, parents and teachers. “It is about resilience,” Gal says. “If they feel under pressure they can find a short movie helping them to breathe better and calm down. It is in both English and Arabic, as well [as Hebrew]. We [also] have a great puppet show that goes around the country. After the show, everyone gets a special Etz Hakochot [Strength Tree] where they write about their strengths. We also do a lot of trauma work in the education system, with first responders, municipalities, factories, businesses who also suffer.” The telephone and other counselors at Natal undergo around a year of training, much of it one-on-one, including with psychologists and other medical professionals. But it also offers training to professionals worldwide who want to learn the lessons of Natal's experience in helping people deal with trauma. Natal is planning a new course at the beginning of 2017 aimed at municipality managers and first responders from around Europe and beyond, who will come to Israel to learn from the organization firsthand. “It is a great international program preparing resiliency for the days before, during and after terrorist attacks,” Gal concludes with an ironic smile and a classic Israeli half-shrug of the shoulders. “We have become more and more professional because, unfortunately, we have more and more experience.” Paul Alster is an Israel-based journalist. His website is www.paulalster.com and he can be followed on Twitter @paul_alster