After the Big Bang, the Silent Trauma Begins

Few casualties and no horrors made adjustment easier in 1991

The green lawns between the buildings where Rivka Douani and Dina Crasanti live in the Ramat Hatayassim neighborhood of Tel Aviv give no hint of what happened there one Friday night 12 years ago. "At six, the table was set for the Sabbath dinner and everyone was home. We heard the warning siren and we immediately ran to the sealed room. Suddenly we heard the boom," recalls Douani.

A shower of glass rained down into the living room and the shutters were ripped from their hinges. A pair of shoes that had been put to dry between the shutters and the window flew into the air. Overnight the neighborhood became a pile of rubble.

An entire neighborhood community was uprooted from homes and evacuated to hotels. Crasanti remembers that she functioned perfectly at the place of refuge in Givat Olga, but when she had to go back home to collect some spare clothing in a bag, "I couldn't find myself." Douani mainly remembers the acrid smell of gunpowder that remained in the air long after the war was over. "The neighborhood looked like a huge graveyard, she says. "Your home, the most protected place, is suddenly damaged and you feel helpless."

After two and a half months they went home and repaired things to the best of their ability. Meanwhile the children grew and the grass sprouted. "All in all, we adapted to the situation," says Douani. "The neighborhood became more unitied, but the wound has not healed."

During that same missile attack, glass was also shattered at the mental health clinic in the adjacent neighborhood of Ramat Chen. During that period teams went out from the clinic to help people who were affected. The cooperation has continued to this day. About a week ago Douani, who in recent years has been head of the neighborhood committee, posted notices in the entryways inviting residents to a workshop on relieving tensions related to stress about the impending war.

The workshop will be led by psychologists from the Cohen-Harris Center for Trauma and Disaster Intervention for mass disaster research and coping, which was established about two years ago by Professor Nathaniel Laor. The psychologists will teach relaxation techniques and how to think during times of panic.

Repressed trauma

The lively interest indicates to Douani that beneath the surface, despite the flow of normal life, people are repressing their anxieties from the Gulf War period. "Many people were afraid of the stigma and did not seek the necessary psychological help. It wasn't legitimate then, as it is today, to talk about the fears. Children in particular didn't get enough treatment."

No one could agree with Douani more than Professor Laor, who has been in contact with her and with the people of the neighborhood ever since the Gulf War. Laor is convinced that proper preparation for the threat of war, even in the most practical sense, could very much diminish the danger of trauma and shock.

Post-traumatic stress disorder (PTSD) affects people who feel that that they have lost control of their lives. However, as a psychologist he also knows that people avoid dealing with a future threat and prefer to bury their heads in the sand. He says he sees this all the time. Only in the past two weeks has "the penny finally dropped, and people in the various systems have begun to tie up loose ends."

Ever since the Gulf War, Laor has been preparing for the mental health damage of the future war. Out of the chaos and the functional vacuum that prevailed then, the foundations have been laid for the center set up by the Tel Aviv Municipality. Today, the center, with its hundreds of personnel, is prepared to build a kind of fabric of teams of professional and key individuals in the community, whose role during wartime will be to give physical and psychological help, to transmit information and to maintain, as Laor puts it, the psychological strength of the community.

Thus, for example, the center has created a connection between the Scout movement and the community of elderly people living in Tel Aviv. The Scouts are helping elderly people prepare their homes for war and are supposed to stay in touch with them during the war.

During the Gulf War, 1,059 people came to hospital emergency rooms and of them there was a high proportion of people who suffered from anxiety - 78 percent. Of these shock victims, 230 were affected by injecting themselves with atropine.

Professor Arik Shalev, the director of the Institute for Trauma Research and Treatment at Hadassah University Hospital in Jerusalem, says it is reasonable to presume that the number of people who suffered from trauma was greater and that many of them were never taken to an emergency room. During and after the war, the first significant research was done on psychological damage to civilians (as opposed to research done in the military on battle trauma) and were published in major international journals.

Trivial start

Today, with developments in the treatment of PTSD and the increase in awareness of the phenomenon as a result of the terror attacks, some of the results of those studies might look trivial. However, they have provided the basis for what is known today.

After the war, Professor Laor and his team began a long-term study of the effect of the evacuation from their homes on mothers and children from the Hatikva and Givat Hatayassim neighborhoods who remained away from home for up to half a year. The study went on for five years and followed more than 200 families with children who were aged three to five during the war.

The families who were evacuated were compared to two control groups - families from the same neighborhood who were not evacuated and families of similar socio-economic standing from Be'er Sheva (a city where no missiles landed). Three months after the missiles fell it turned out that the two control groups had returned to normal functioning.

Among the group that had been evacuated many symptoms of battle trauma were observed in the children and their mothers - sadness, depression and anger that were channeled into tantrums and behavior problems (among the children). The mothers suffered from repeated brooding on the event and adopted behavior that the experts call avoidance - among other things, they did not go near the place where the missiles struck, or their homes.

Two and a half years later, 50 of the families from the group that was evacuated and from the control group from the same neighborhood were interviewed again. Overall, according to reports from their teachers, it turned out that the children from the evacuated group had adjusted. However, there were still children among them who suffered from symptoms of PTSD. An interesting connection was found between mothers and their children: The more mothers were exposed to trauma and suffered from symptoms, the more their children were psychologically affected.

During the third stage of the study, four years later, it was found that children who naturally developed effective and mature coping mechanisms, such as humor or sublimation, managed to do well even if their mothers still suffered from post-traumatic symptoms.

Art therapy

Following this study and a study carried out among mothers and children at the Israeli vacation village in Turkey after the earthquake, members of the team developed a method of short-term therapy for mothers and children, which was successfully tried on patients with anxiety disorders as well.

In about 10 group therapy sessions they try to untangle the knot of anxiety and return to the mother her role as comforter. The treatment combines discussion and role-playing, art therapy (for the children) and the rehabilitation of avoidance behavior - by accompanying the patient to the scene of the disaster, for example.

Part of the 1996 study that is forthcoming in the Israel Journal of Psychiatry will be devoted to the attitudes toward Arabs of children aged 8 to 10 during the Gulf War. It was found that there is a direct correlation between anxiety symptoms and extreme attitudes towards Arabs. The children who suffered from PTSD also were pessimistic about peace. Rivka Douani expressed a similar idea when she objected strenuously to "Arabs who danced on the rooftops with joy about what happened to us" repairing her home. Years later she has moderated her feelings and has even been involved in various coexistence initiatives at her job at the Peres Center for Peace.

Many studies were carried out while the missiles were still flying. At the time, Professor Zahava Solomon, an epidemiologist at the Tel Aviv University social work school, was head of the mental health services in the Israel Defense Forces. "The body of knowledge already existed in the army because of the extensive experience with battle trauma," she says.

Psychologist Yuval Neria, who was her student, encouraged her "to take advantage of the war instead of sitting at home and doing nothing." In cooperation with the universities, Solomon supervised scores of observations in various populations. Between August and the post-war period, in the framework of the army, 8,000 men, women and children who represented the population of Israel were studied. Special populations, such as the mentally ill and Holocaust survivors, were also studied.

The findings of the study were published in the book "Coping with War-Induced Stress: The Gulf War and Israeli Response" (Plenum). The findings indicated contradictory trends. In general , people reacted in a very reasonable way during the Gulf War, says Solomon. She attributes this coping in part to the high degree of trust in the government and the army, which exists today as well.

Contract with Saddam

The day to day tension was not static, she says. "During the day there was calm and the level of tension rose gradually toward evening when people put on their war uniforms - sweat suits - and showered quickly and got organized to sit in the sealed room. And then, like on a bell curve, tension went down after they came out of the room." During the first incident, more than 200 people injected themselves with atropine, she recalls. "People got hurt when they bumped into things after getting disoriented. But the relatively high rate of panic declined after the first incident receded and there was a degree of adjustment."

Solomon attributes this admittedly strange adjustment by the Israelis to the creation of psychologically protected territories. "It was as if there were a contract with Saddam. People tended to believe that he would bombard every day at the same time and they created for themselves islands of rationality and organization."

According to her this is also the difference between a period of terror attacks and a period of war. "A terror attack can't be predicted at all. It's a completely random matter, which means a total loss of control."

But there is more to the difference between a period of terror attacks and war. During a war, at least like the one in 1991, which was conducted through the media and in which there were no casualties, an important element in the post-traumatic context was lacking - scenes of bleeding victims and body parts, which cause a state of shock. Also according to Professor Shalev of Hadassah, the fact that there were few people injured during the Gulf War contributed to the relative calm.

Is this good news in the context of the impending war? Shalev notes that the sight of the mask and the threat of gas automatically raises the level of anxiety. Being inside the mask, according to him, slightly elevates the amount of carbon dioxide in the body, and not everyone responds to this with indifference. However, both Shalev and Solomon emphasize that most people cope and adjust to the situation.

"When a population is under stress, it is possible to predict that most of it will function, despite the initial natural symptoms," says Shalev. "Mass panic is always expected at a time of disaster, but this is not necessarily the case. People around the world have organized at times of disaster and survived. There is a small group that does not respond well and for them the symptoms do not pass on their own. This also depends on the extent to which the group is involved in the disaster."

It is now known that the degree of this involvement also depends on the extent of exposure via television, which is greater today than it was in 1991 because of the multiplicity of channels and the competition among them. Solomon says that "the media are now building up panic among the public instead of being functional and transmitting information."

This also happened during the Gulf War. According to her they filled the many hours of studio time with psychological advice given by various experts. She believes this was a mistake and that at times of stress it is not a good idea to open things up too much and "put an entire nation on the psychologist's couch."