Queen of Broken Hearts

Prof. Edna Foa, an Israeli psychologist at the University of Pennsylvania, has developed a breakthrough therapy for post-traumatic stress disorder that has been successfully adopted by the U.S. army. This year, Time magazine named her one of the world's 100 most influential people. But in Israel, her method is still fighting for recognition.

"It was funny," says Prof. Edna Foa in the living room of her apartment on Yohanan Hasandlar Street, on the third floor of a Bauhaus building overlooking Sheinkin Park in Tel Aviv. "Since I tend to delete everything I can in my e-mail inbox, my secretary called me to say that I had received an important mail that I absolutely must not delete. I was out of town at the time, and when I eventually got to a computer, the e-mail in question indeed looked to me like one of those mails announcing that you've won a million dollars, a scam. When I read the details, I thought for a moment that it was a joke. After all, I'm not a film actress, not a politician, not a soccer player and not a celebrity. I thought to myself, how the heck did I get on this list?

But she knows exactly how. Foa, an Israeli clinical psychologist who directs the Center for the Treatment and Study of Anxiety at the University of Pennsylvania in Philadelphia, was placed this past April on Time magazine's list of the world's 100 most influential people in 2010. A unique method she developed for the treatment of individuals suffering from post-traumatic stress disorder (PTSD ) and anxiety was the reason for her inclusion in the special edition. As she recalls with amusement the way the magazine editors chose to inform her of her 'win,' she skims through the issue, lying on a glass table in front of her. Featured on the glossy pages are assorted icons that include President Barack Obama, singer Lady Gaga, Chelsea footballer Didier Drogba, Apple CEO Steve Jobs, and the head of the opposition in Iran, Mir-Hossein Mousavi. "Here I am," she suddenly says, and an embarrassed smile flashes onto her face.

Lea Golda Holterman

The judges' reasons for selecting Foa, who has lived in the U.S. since the late 1960s, leave no room for doubt - the Americans hold in the highest regard her breakthrough research contribution. They consider her the queen of broken hearts, the rescuer of lost souls, who should be treated with a reverence reserved for precious few mortals. "Human beings are hardwired to fear things - the lion in the grass, the assailant in the alley - and if one of those fears gets realized, we may never settle down again," Time wrote in a sensitive article describing her work over the years. "The pain associated with that condition is known as post-traumatic stress disorder (PTSD ), a mix of depression, anxiety, anger and isolation. No one is doing more to end that suffering than psychologist Edna Foa, 72, of the University of Pennsylvania."

Foa is not letting all the nice things they're saying about her go to her head. On the contrary, seated on a couch, wearing a black dress adorned with gold and silver butterflies, she feels a need to keep some distance from the American newsweekly's embrace. "It isn't something that is that important to me," she says, in an effort to chill the warm compliments. "It's a magazine, not the center of my life. I'm happy about it, I thought it was fun, and I was amazed that without engaging in politics and without a public relations machine I received recognition for my work. However, my personal role in all this will be ending pretty soon. I'm happier about the publicity that led to increased awareness of a subject close to my heart. Because there are so many people around the world suffering from traumas caused them in the wake of terror attacks, wars and natural disasters. Greater attention to treatment of trauma can help them a great deal. I feel that is the most important aspect of the story."

Patterns of fear

During her visit to Israel in June, Foa, who lives in the Philadelphia suburb of Penn Valley, says the recognition she is now receiving is the result of dreadful battlefield events. She notes that in the U.S. alone, about half a million Vietnam veterans and more than 300,000 soldiers who have returned from Afghanistan and Iraq suffer from PTSD. Given their prolonged and continuing state of distress, a professional committee was assigned to examine various means of aiding their rehabilitation. In 2007, the committee recommended adopting Prolonged Exposure therapy (PE ), a technique for individuals with PTSD and anxiety disorders developed by Foa over the past 30 years.

"PE is based on principles of cognitive behavioral therapy, and focuses on imaginal exposure of the victim to the past traumatic event in a repeated, controlled and prolonged manner," she says. "The therapy focuses on contending with invasive thoughts and the patient's attempts at avoidance of trauma-related memories. This exposure enables the patient to differentiate between the traumatic event he underwent and events that are not traumatic, and in that way cease to experience the world as a dangerous place. At the end of the process, the therapy enhances feelings of self-control and reduces the sense of helplessness that exists among patients. Numerous studies that examined the effectiveness of the technique revealed that it leads to a significant reduction of post-traumatic symptoms among more than 80 percent of the patients."

This was not a simple process to develop, she says. Over the course of many years, she has continued to revise and improve the therapy, thereby increasing its effectiveness. The first steps on the long road were in the early 1980s, when she wondered why it is that, unlike positive experiences, negative experiences remain with us and hound us. "I tried to understand why wonderful sights do not come back to us in flashback, while we relive over and over the negative events, the sort that stimulate distress," she says. "I was not thinking then in terms of PTSD and pathology, it was a more general thought. I had seen this phenomenon in literature and in life, and asked myself why it happened. Why do certain memories of harsh experiences hound us without relenting?"

Foa, then in her early forties, supposed that the individual evidently had a need for repeated processing of the negative experience. "I thought that if we invested the mental resources in processing the negative experience, it was apparently important. Since these experiences threaten us and our social, psychological and bodily existence, we have a need to learn from them. They are critical to us in order to survive. Peter Lang, my mentor and one of the mainstays of thinking on anxiety, developed concepts that help us to understand what anxiety and fear really are. He began with the idea that fears are cognitive patterns whose role is to protect ourselves from dangers. In one of his many articles, he wrote one single line in which he said that an important element in treating anxieties is 'emotional processing.' That is where my theory started."

In 1982, working with a student of Lang's, Michael Kozak, at Temple University in Philadelphia, Foa began diving into the depths of anxieties. "I met with Michael nearly every day, for almost two hours," she recalls with delight. "We devoted a great deal of time to this subject. Today, I wouldn't find two hours a day to devote to developing a theory. Anyhow, we wrote a paragraph a day; if we had greater success and hadn't argued too much, then we wrote two. Our point of departure was that in every fear pattern in the brain there is information about the frightening stimulus and the response to it - say, a fear of large animals like lions and tigers that automatically causes us to run and hide. But we said that these patterns are normal because they are protective. Later on, we began to concentrate on pathological structures of anxiety, and for the first time described anxiety disorders as pathological structural reflections in which people fear stimuli that are not dangerous, for example elevators, crowded places and one-way streets."

At that point the thoughts broke new ground. "Our theory contends that the reason why pathological fear patterns are created is related to our avoidance of processing negative experiences," Foa added, speaking more rapidly. "Meaning that every time we have a thought that hounds us about the trauma, instead of trying to process it, to give it space, to deal with it - we shove the traumatic memory aside. As opposed to Lang, who spoke of stimuli and responses, we emphasized the significance and interpretation of the frightening stimuli and our responses to them. We understood that the significance alters the way we feel and the way we respond to a stimulus. As an example, a lion in a living room induces fear, but a lion in a zoo will induce in us thoughts about the beauty of wild animals."

Ivory towers

Foa was born in the winter of 1937 in Hadar Carmel, Haifa, to elderly parents. Her father managed the insurance department at Solel Boneh, her mother was a housewife. "I had a brother, who was seven years older than me, a Palmachnik, who was killed in one of the attempts to break through to the Negev in 1948," she recounts. "I was 10 years old at the time, and I was left the only child to bereaved parents. It was then that we moved from Hadar Carmel to Neve Shaanan. That is where I spent my youth. I attended the Reali School, a rigid school that offered an outstanding education. The school principal, Dr. Arthur Biram, who came from Germany, adopted the German curriculum, and we learned art and Greek philosophy; we read Greek tragedies, the Odyssey and Freud. I had wonderful teachers then; Baruch Kurzweil, for instance, taught me literature." After she graduated from high school, Foa began, with her mother's encouragement, to train as a teacher at the Kibbutz Seminary in Oranim. "Because my brother had been killed and I was an only child, my mother didn't want me to enlist in the army. I, who was a member of the Mahanot Olim youth movement, of course objected. I very much wanted to enlist and to go and volunteer on a kibbutz. My father passed away when I was 14, four years after my brother fell, and my mother asked me to postpone my army service. In the meantime, in exchange, she offered to pay for my studies at the Kibbutz Seminary. She told me: 'When you complete your studies, if you want to go to a kibbutz, at least you'll work there as a teacher and not milking cows.' It was sort of a bribe so that I wouldn't go into the army," says Foa.

At Oranim, an unexpected change took place, one that opened the door to a journey that would eventually place her among the world's leading experts in the field of behavioral cognitive treatment of anxiety. "In high school, it was obvious to me that I would go on to university and study archaeology or history," she continues. "But in the course of my teaching studies, a doorway opened for me - I began to develop an interest in psychology. I wrote my final paper, for instance, on juvenile delinquency. After completing my studies, I got a job in an institution for juvenile criminals in Ramat Hasharon, which was located in the sand dunes there. Now it is all built up. At the end of a year in which the children jumped on tables - big, strong children that I was sometimes afraid of, who did not want to hear what I wanted to teach them - I realized that if I really wanted to help them, I should be a psychologist, not a teacher."

In mid-1960, the young woman from Haifa applied for undergraduate study of psychology at Bar-Ilan University. However, to her surprise, she soon received a negative answer from the department she yearned to attend. "They didn't accept me because I had studied at the Kibbutz Seminary, and they ate pork there," she explains with a smile. "But I didn't give up. I went to the head of the department at the time, Prof. Siegman, who was a very religious man. I told him that I wanted to learn psychology, even if I wasn't religious, and that I promised to behave as I should in a religious setting. He replied that he would think it over and a few days later he called me in to him and said, 'What we can do is this: you will audit my two courses. If you do well on the examinations, I will stand by you, and push for you to be admitted.'"

She met the stringent conditions set by Siegman and continued her studies, during which she met the late Prof. Uriel Foa, her first husband and the father of her three daughters, who now live in the U.S. "Uriel was then an associate professor in the psychology department, and I was a young student," recounts Foa, who has for the past 22 years been married to an American professor of Greek philosophy. "In 1966, when I was 28, Uriel was invited to come to the University of Illinois in Urbana as a visiting lecturer. While there, I pursued my M.A. in clinical psychology. My thesis concerned personality structures of psychotics and neurotics. Then we left Illinois. I wrote my Ph.D. at the University of Missouri in Columbia, on cognitive structures of aggression and frustration."

Her wandering among American ivory towers did not end in Missouri. The next stop was Temple University in Philadelphia, home of the father of behavioral therapy, Joseph Wolpe. "I thought it would be interesting to work with him," she says. "He revolutionized therapy technique. Wolpe believed that anxieties are the result of conditioning, that a specific event caused a person to fear. He taught me to work with anxiety disorders using a behaviorist method, despite my being more cognitive. As opposed to the behaviorist outlook, which posited that cognition is not important - send a person to an elevator, he'll see it is not dangerous, and he will modify his behavior patterns - the cognitive outlook claimed that it is the modification of a person's cognition that will modify his behavior. Then, as now, I am in the middle, between these two outlooks."

New interpretation

Prolonged Exposure therapy (PE ), consisting of between 8 and 14 ninety-minute weekly sessions, seeks to confer a new interpretation on traumatic memory. The object is to induce the patient to frame his emotions in a new way that will enable him to gain control over the memory and resolve it. "We want a therapy that will help the patient understand that the anxiety from which he suffers is not realistic," Foa emphasizes. "If a patient who was raped thinks that every time she walks down a dark street she will be raped, or a soldier who served in Lebanon thinks that every time he goes to Jaffa he will be attacked - these are assumptions that do not correctly reflect reality. The fears of people with PTSD are unrealistic fears."

As a result of these fears, she explains, two primary types of avoidance are created. "The first, avoidance of thinking. Post-traumatic people don't allow themselves to go into trauma again, to think about it, because they don't want to feel distress, are afraid of falling apart from it, afraid of breaking, of going crazy. The second, avoidance of going to places that remind them of the trauma, because the individual doesn't want to expose himself to danger again, to a similar situation. I tell them, 'Let's get into it again, let's invite the traumatic memory, it isn't your enemy.' This harsh memory lives inside them, it is their experience, although it is very difficult, but they need to process it and learn to live with it."

Couldn't this sort of repeat exposure also cause damage?

"A good exposure is an exposure that ensures corrective experience. In the course of the therapy we protect the patient, seeing to it that he doesn't get too far into the experience, although that does not happen much with post-traumatic people, since people with PTSD symptoms know how to protect themselves. That is precisely the problem, they are experts in avoidance and do not easily connect with their feelings."

How do you put the patient into a state of trauma?

"I ask him to tell about the trauma, in present tense, so that he will be able to connect emotionally to the story. We know that if they talk about the trauma without emotions, as if it were a police report - it doesn't work. You have to talk about the trauma with emotional accessibility. Emotional processing requires the experiencing of the trauma as it happened. I also record the patient's story and let him listen at home to the recordings, over and over. It is hard at the beginning, as if you were seeing a very scary movie for the first time. But just like a movie, when you watch it for the tenth time, the fear is forgotten and the movie gets boring."

What does the patient discover during this process?

"When he retells and listens to his traumatic story over and over, the patient discovers that he is not falling apart and is not breaking down. On the contrary, the more times he tells it, the more his anxiety decreases. The traumatic memory had controlled him, and as the therapy progresses he feels that he controls the memory. At the end of the therapy, the traumatic memory takes on a new perspective, a different meaning. What happens is that in the course of the treatment, they discover new details of the story; in the past, they did not allow themselves to delve into it."

Could you give an example?

"A soldier, an Israeli medic, told his therapist, with feelings of humiliation and guilt, that during the battle he did not function, that he did not help his friends, that he was paralyzed by fear. That is what he remembered, and that is what informed the primary meaning of his traumatic event. But when, as part of the imaginal exposure, he delved into the details, he in fact discovered that he had worked very hard, that he had saved people. He did not suppress the memory of these details; he simply did not give himself the opportunity to recall all these details, because he had rejected out of hand all distressing thoughts of the trauma. Another example: a young woman in the U.S. who was raped by eight men she knew. She claimed that if they had only known she was not enjoying the sexual experience, they would have stopped. That was her dominant feeling. But the imaginal exposure raised another picture. It developed that she remembered having fought them off, that she scratched and bit them. In this way, her story took on a different meaning."

Support system

A formative moment in Foa's treatment technique occurred in Israel, when she arrived for a visit in September 2000. "I came to Israel for a three-month sabbatical," she says, although she instantly clarifies that she "never goes on sabbatical. I have too much responsibility at the center I direct at the University of Pennsylvania, and I cannot leave for a long period of time. But nevertheless, we said at the time, my husband and I, we'll go to Israel, we'll have a good time, I'm tired and I'll get a little rest. I thought I'd get up in the morning, first open one eye and after a while the other eye. That I would eventually ask my husband where we should go today. To a gallery? On a hike? To a museum? That was the plan."

However, five days after her arrival in the country, the Al-Aqsa Intifada broke out, and the violent events in Israel and the territories disrupted the plan of finding a little quiet. Instead, Foa was again swept up in intensive work. "I was supposed to give a small workshop for 30 therapists at Tel Hashomer Hospital," she recalls. "Out of the blue, 140 people showed up at the hall. It looked like an insane asylum. I received a ton of requests on that sabbatical; people heard I was here, they knew that my expertise was PTSD therapy. I was asked to give workshops near and far. Instead of going to art galleries, I was working nonstop. But the most significant thing that happened was when I began an initial attempt to institutionalize the technique in Israel. I thought about a method in which, even when I would not be here, Prolonged Exposure therapy would work, and patients would receive treatment."

She realized that in order for her therapy technique to strike roots in Israel, she would have to run as many workshops as possible for therapists who would adopt her methods. With the help of Ashalim (an NGO that develops services for at-risk children and youth ), the National Insurance Institute and the Israel Trauma Coalition, numerous workshops were offered at the Ministry of Defense; for guidance counselors and educational psychologists at the Ministry of Education; and at various treatment centers throughout the country.

"Some of the therapists who completed the workshops did not assimilate the technique in their work, but many did begin using it with success," adds Foa. "That is what happened, for instance, at Haemek Hospital [in Afula], Rambam in Haifa and Hadassah in Jerusalem, where they began to use PE as an instrument in their treatment of trauma."

What did you learn during the process?

"Through trial and error, I learned for the first time how to implement and assimilate a psychotherapeutic treatment technique. We selected the best and most devoted people who had undergone our training, and then trained them to be instructors who would lend assistance and aid to less experienced therapists, to those who had only completed the workshop. After 2000, in the course of the next three years, we trained 20 Israeli instructors at our center in the U.S. and 10 more at Sheba Hospital in Tel Hashomer. That is how I learned to create a support system. Giving a workshop is no big deal; the difficulty lies in ensuring a framework to preserve these gains that is not dependent on any one person."

In fact, it was only after you constructed this model in Israel that you began to popularize it in the U.S.

"True. In 2007, when American soldiers were returning from Afghanistan and Iraq, the Veterans Administration, which is the public medical system for army veterans in the U.S., was inundated with PTSD sufferers. Until that time, they'd sit with them in group meetings that did not exactly produce results. As in Israel, where people receive treatment through the Defense Ministry for 20 or 30 years - treatments that do not help them get better or resume everyday functioning - the same goes for the VA.

"That year, the results of a VA study were published, which examined how PE worked with 300 American women who had been in the army. The results were outstanding, and since the technique had received scientific proof of its effectiveness, VA administrators approached me and asked me to help them build a system that would implement PE throughout their nationwide network. I told them, let's try to apply a similar process to what I'd done in Israel. And that is how we started to train the VA therapists. We started with eight workshops, with 40 people in each. In addition, we built a system of instructors and teachers. There are now 1,100 therapists, and the number is constantly growing. There are 80 instructors and 18 teachers and we, the Center for the Study of Anxiety at the University of Pennsylvania in Philadelphia, only serve as an advisory body."

After all this, the Association for the Advancement of Behavior Therapy in the U.S. awarded you a prize for your scientific contribution and a prize for your achievements during your years of work. The American Psychological Association awarded you three prizes: for your scientific contributions to psychology, to clinical psychology, and to knowledge related to responses to trauma. Here in Israel, it seems as if your technique has still not received the recognition it deserves. Are you disappointed?

"It isn't a personal disappointment. I don't have the time for personal disappointments. I do understand that it is very difficult to introduce new therapy techniques into the existing system. Psychodynamic therapy is part of the tradition that is highly emphasized in Israeli universities. Although the influence of cognitive-behaviorist therapy is increasing, the psychodynamic tradition is still strong. Look, there were attempts to introduce the technique into the IDF, for example in the combat response unit, but it was not successfully integrated. We trained a large group of therapists and instructors there, worked very hard, but many therapists moved on to other positions and stopped treating PTSD. Others left the army. Even the chief army psychiatrist left, after beginning to introduce the technique. At a certain point we had to start the whole thing from square one, and I gave up. The Defense Ministry did adopt the technique, in the framework of a committee headed by Prof. Yossi Zohar from Tel Hashomer; it was decided to introduce the technique as part of three or four therapy techniques for PTSD. But I don't know what the real value of that decision is."

Isn't it a shame that people who are suffering are not getting treatment that could save them?

"It's a big shame, but I am realistic. It will take time until public bodies like the Health Ministry or the Defense Ministry decide to adopt the technique as was done by the VA in the U.S. I hope it will happen; it must happen. The Defense Ministry pays a fortune to keep post-traumatic people in treatment that goes on for years. It isn't merely an ethical issue, it is also a financial issue. Here you have a technique that will help people to function within 10 to 15 sessions. Which is why this technique will eventually win. It has to win. In the meantime, I've done what I can." W