Yael Caspi : The psychic consequences of war on veterans of the Israel Defense Forces and their families

Freud committee, Tel Aviv on the 29/02/2016


I would like to share with you today a comprehensive understanding of the impact of combat-related psychic trauma. I will describe the vicious posttraumatic cycle and the growing damage to the sense of self and the substantial transformation and breakdown in self-capabilities. I will present a conceptual model for intervention with veterans of the Israel Defense Forces (IDF) who suffer from severe posttraumatic disorders. I will present the concept of post-traumatic shame as the key to the complex trauma reactions encountered in veterans from non-Western backgrounds and to the establishment of the relational bond necessary for their engagement in the treatment process. I will utilize examples from clinical and research work with veterans, including those who come from Bedouin and Druze villages in the north of Israel.

In my talk, I will not mention by name the many scholars whose work I read and who influenced my thinking over the years. I reference them when I write and ask that you trust that I give them full credit.

Let me begin by clarifying that my talk today is based on experiences with those combat veterans of the IDF whose posttraumatic distress reached a level that required intense professional intervention.

As long as the definition of PTSD was based in the formulation of a fear-based disorder, the changes in personality that almost always accompany it granted patients with many co-morbid diagnoses, mainly major depression, substance abuse, and personality disorders. In the DSM-5, persistent long- term alterations in cognitions and mood were added to the revised definition of PTSD, including emotional states, such as fear, horror, anger, guilt, and shame. This addition highlighted the central


role of emotional dysregulation in posttraumatic disorders. The increased autonomic responsivity is often expressed through anger and shame, and the emotional numbing and detachment is reflected in experiences of depersonalization and derealization.

Many veterans seek treatment only after years of living the downward spiral of failed employment, broken relationships and impaired physical health. Most of the men we treat developed the disorder after multiple traumatic events. They engaged in coping efforts that, much like a car stuck in mud, only led to a massive breakdown in their sense of self and self-capacities. In addition, nearly all systems are affected – cognitive, emotional, physiological, relational, vocational, functional... self and body regulation is severely impaired. Sleep is often limited to 2-3 hours, interrupted by nightmares.

Indeed, one of the central problems for those suffering from chronic PTSD is the damage to the sense of self-efficacy. Self-efficacy is the belief in one's ability to exercise control over one's environment, and one's level of functioning. A vicious cycle is created once experiences of poor cognitive performance, the constant sense of danger and the reduced ability to meet challenges cause significant impairment in self-esteem. This, in turn, intensifies self-doubt and loss of faith in one's capabilities and leads to anticipatory failure, increased anxiety arousal, dwelling on coping deficiencies, and depression. Reduced self-efficacy becomes both an outcome and a predictor of the long-term effects of traumatic experiences and further exacerbates the posttraumatic symptoms, thus consolidating the sense of "discredited personhood" (Peskin, 2012).

For those trying to maintain a form of normalcy, even the simplest tasks of daily living, such as going to the bank, the car mechanic, the grocery store... become major struggles in a universe that seems to have turned hostile, judgmental, persecutory, and ridiculing. Every expectation from them turns into a mirror that reflects their inability to be who they are supposed to be. The wife becomes an enemy when she expects gestures of warmth and intimacy that are no longer possible for most men with severe PTSD. Similarly, a little child raising her arms to be picked, quickly generates anger and frustration that may be released through some excuse to get mad and leave the room. "I look at my children and my heart is empty, I feel nothing" a patient said with tears in his eyes "they deserve a real father. It would have been better if I had died".

Multiple health problems accompany the severe stress reactions. Headaches, severe stomach problems, chronic and persistent bodily pain, severe sleep problems, high blood pressure, diabetes, heart problems, eating disorders, infections... The body is chronically stressed and highly reactive. On top of that, are the dissociative states; many veterans suffer from dissociations and flashbacks that can be triggered by multiple reasons, including certain smells or sounds. They oftentimes are not able to recall what triggered them which practically means that they are constantly at risk of literally losing themselves, with almost no ability to predict when and where. The impact on self-esteem, self- confidence, is clear. One patient told me it became impossible for him even to view football matches on the television with his family members because he often disconnects during the game, only to 'wake up' by the cheers of the people around him, having completely missed the actual goal.

If viewed from the perspective of self-efficacy, it becomes clear that there is no respite from feelings of loss of control and the self-disgust and shame that come with it. Unfortunately, attempts to withdraw completely and to be left alone, as many of our patients try to do, do not provide much help; detaching themselves from the daily routine of the family, social events, the media – only worsens their sense of inadequacy and creates even more distance from the 'here and now'. Patients often describe loss of time - finding themselves after many hours had passed sitting in the same position, deep in thoughts, reflecting on the life they used to have and their current situation, in and out of flashbacks and traumatic memories.

Capable men become dependent on everyone close to them who is willing to take on the thankless task of caring for their needs. They need someone to be their representative. When their humiliation is too deep to allow help, the family usually suffers from financial problems, their own health deteriorates, and nothing is well managed. This dependency brings on further regressed and reactive behaviors, such as anger and aggression.

In our clinic, there are many patients who come from Druze and Bedouin backgrounds. The Druze (men only) are required to serve in the IDF like Jewish israelis. The Bedouins volunteer for service. Both groups are ethnically Arab, they usually live in villages that consist of large tribal families. The Bedouins are of Muslim faith, but keep apart from the larger sub-group of non-Bedouin Muslims. The Druze faith separated from Islam around the year 1000 and was declared closed shortly after.

Each group has a separate education system, they marry within themselves, and maintain traditional, collectivist values within their communities in the complex Israeli environment.

Quite a number of our patients who come from these backgrounds seem to have basically 'checked out'. No longer among the living, yet unable to commit suicide due to strong cultural beliefs. For example, a man in his thirties who sleeps in his parents' bedroom and will only shower if his mother is present; another who has a room in the basement and is confined to it for most of the day; yet another who spends most of his time in the woods, with horses and farm animals. Some of these men seem so disconnected from reality that they are sometimes viewed as psychotic or suffering from schizophrenia. Mental Death (Ebert & Dyck, 2004) and Collapsed Self (Boulanger, 2007) are a few of the terms that best capture the true magnitude of the long-term impact of severe adult-onset trauma.

Indeed, it is our impression that the psychotic like flashbacks and their effect on thought processes are more common among veterans from Druze and Bedouin backgrounds. The plausible reasons for that are beyond the scope of this talk. However, I would like to briefly describe this to you, so you could appreciate the challenge in engaging these men in therapy relationship and in the treatment process.

The man I will describe (this is actually a composite case) was a soldier in a specialized combat unit during the days of the second Palestinian Intifada, or uprising, which lasted roughly 4.5 years from September 2000. He started to see the dead when he was still in service - his dead friends, as well as the people they killed. He knew this meant that he was not well but continued for a long time and completed his service, not telling anybody about this. He fell apart after he was discharged. He continues to hear voices and to see the dead as if they were alive. He feels unsafe all the time, no matter where he is, afraid that relatives of the dead Palestinians will find and kill him in revenge. Every sound can trigger a flashback, during which his eyes become glossy, his body is frozen, and his breathing becomes shallow. It is difficult to snap him out of it. He describes it like a detailed movie of the actual events he was involved in, and re-experiences the danger but with a sense of horror that was absent in real time. There are also details he has never shared, which I assume refer to violent actions that were not necessary for self-defense. When I ask what he thinks happened to him, he says that he went too far a distance from the values he was raised on, and that he cannot return, that he is stuck "outside humanity". He says that he is living like an animal, focused on surviving each day, and that he wishes to stop this but is afraid to take his own life.

Going back to the theme of loss of self capacities –I would like to suggest that for veterans from Jewish backgrounds, anger and aggression are the primary ways of reacting to the loss of self- efficacy, while for men from Druze and Bedouin backgrounds it is what we refer to as shame, or loss of face.

Being assertive, fighting for your individual rights...these reflect values that are based on Western cultural codes regarding the boundaries between self and other, and the interpretation of expressed emotions. For a Bedouin combat veteran, angry outbursts, although not uncommon, are like a declaration of dependency and neediness, another 'proof' that he can no longer provide for himself, that he lost his autonomy and self-respect.

Anger, aggression, shame and guilt are commonly experienced by all who suffer from PTSD. However, the reprocussions for self and family that are associated with the damage to the sense of capability and self-control, seem to be more devastating in collectivist societies.
The wellbeing of the group in these societies, this collectivist entity, is protected by way of the individual's loyalty, duty, honor, respect, sacrifice, and – so important for us to understand - self- control. The loss of face, loss of self-continuity, leads to the experience of ego fragmentation, self- dissolution, and de-realization. The inevitable sense of public humiliation is experienced as a fate worse than death.

Anthropological studies identified a type of honor in the Arab culture that is related to the values of strength, modesty and freedom. Emotional and behavioral expressions that suggest vulnerability are sanctioned, as we can see in the limited mourning rituals allowed in Muslim societies. Underlying this there is also the notion that inability to accept loss of any kind, is to admit a lack of autonomy and self-control, as well as to express defiance against God's will. Assuming all these are cultural codes not readily available to the conscious mind, it is clear how posttraumatic shame becomes an isolated prison cell.

Having described all this, I would now like to present to you a conceptual model with intervention guidelines that is based on the understanding that the lack of self efficacy that comes with PTSD and the feelings it generates are the first and biggest challenge of treatment and the therapeutic relationship.

The guidelines draw from several theoretical and clinical formulations and different patient populations; they are interconnected and, together, form a comprehensive approach centered on the vicious cycle of impaired self-efficacy. I believe that in veterans from non-Western backgrounds posttraumatic shame is at the core of the impaired self-efficacy and should be addressed directly.

There are seven components to this model:
Psychoeducation: the psycho educational approach, drawn from the cognitive-behavioral teachings, assumes that the patient should have knowledge of his problem and can be helped to understand it. The direct approach has been identified as efficient and acceptable by Arab patients as well as refugees from different backgrounds. The problems are demystified, rationally explained, and the person is gradually able to comprehend their own behaviors and emotional state. The therapist is in the role of teacher, advisor, and problem solver. The attachment to the therapist is made possible by this authentic, direct, and involved rapport. Flexibility in regards to the standard boundaries of the therapeutic relationship is recommended (e.g., calling the patient between sessions), as well as a very tenacious approach. Hope has to be held by the therapist for a long time during a process that yields only small and hardly noticeable improvements.

Phased treatment. This concept emerged from the clinical literature on survivors of severe childhood abuse who develop complex forms of post-trauma and require an initial and lengthy period to develop and improve fundamental self-based coping skills.
It is important to realize that although people experiencing posttraumatic impairment following adult-onset trauma used to have functional and adaptive self-capacities, these skills are no longer available to them. The role of the therapist is to be active and to explain about trauma and post- trauma, with a clear message about Safety First. The trauma story is deliberately not discussed in detail until a better understanding and self-control are achieved.

In our clinic, patients first participate in a PTSD and anger management group where the explanations about the posttraumatic disorder are focused on emotional regulation and learning to pay attention to distorted interpretations of everyday events, identify triggers, and control angry outbursts.

The next step is the PTSD and sleep management group; very little energy can be expected from people who do not sleep. Having already learned about emotional-regulation and self-relaxation techniques in the anger group, they now focus on their sleep hygiene, aiming to insert safe images into the nightmares.

Safety is a thread that goes throughout all the interventions. Because we begin with the idea of minimizing damage, containing the ever-widening circles of loss, we focus on self-control over anger and aggression. We include family members for psychoeducation about trauma and PTSD. Druze and Bedouin families may be unaware of these terms and how they relate to the profound change in their son or husband. By forming alliances and active involvement with family members, they can learn to better avoid crises, and also become a resource of support at a later stage of treatment, when direct trauma work may cause temporary regression in the veteran's behavior. Safety is also understood in terms of veterans' physical health and financial security.

Case management. Much can be learned from the literature on dual diagnosis in terms of its recognition of the relationship between traumatic life experiences and the risk for additional medical and social complications. Patients are unable to take care of their many needs, to prioritize them, or to delegate them... For Druze and Bedouin patients, stigma and the vicious cycle of posttraumatic shame make it even less possible. Concretely, we maintain ongoing contact with physicians and social workers in the MOD and with the primary care physician and social services in the community.

Patient Advocacy. One of the most persistent sources of distress for veterans is the process of claiming injury-related benefits and dealing with the bureaucracy and the medical committees in MOD. Many experience these processes as lack of respect, and voice the feeling of being forsaken in battle by the same state they were fighting for. The common image they refer to is of a beggar pleading for favors. Advocating for the veteran is an integral part of the treatment plan. By maintaining on-going relationship with the decision makers at the MOD, a better synchronization is achieved between the treatment and rehabilitation goals and MOD regulations. Letters describing the patients' psychiatric and psychological status are written for patients, in compliance with medico-legal and ethical principles. In specific cases, especially when additional community organizations are involved, we initiate multidisciplinary meetings, and follow-up on implementation of decisions.

Illness management. Given the absence of integrated care, patient engagement with self- management is critical for the outcomes of chronic conditions. The impairment in self-capabilities is the primary barrier to patient activation. Consequently, we transform tasks related to self- management into treatment goals. Psychoeducation regarding the expected difficulties should include concrete exercises, such as standing in line in the bank, surviving the doctor's waiting area without fleeing, or remembering what to report to the doctor. The difficulties experienced are analyzed in detail during the therapy session and explained in terms that gradually become familiar to the veterans. All aspects of daily life, from marital relationship to shopping for food, are discussed in terms that allow the veteran to regain control of his mind and his behavior, and to learn to manage his disorder.

Rehabilitation. The focus on rehabilitation frames the expectation of creating normalcy, even at a very basic level. For example, one of the first treatment tasks to pursue is sitting down for dinner with the family, even for only a part of the meal, while controlling their reactions. In the therapy session, this most routine event can be broken down into small elements, and different suggestions played out to create an arsenal of relevant coping tricks. Success is defined as a meal not interrupted by abrupt departures or angry outbursts. The concrete discussion about the meal leads to open descriptions of the patient's inner world, and creates yet another opportunity for the understanding of the vicious posttraumatic cycle: The thought that "the children can see that I am not normal" increases bodily tension and posttraumatic sensitivity to sudden noises (e.g., children bursting into laughter). The potential loss of control (screaming at the children) is followed by the worsening of the self-loathing (I am weak, I am nothing) and the exacerbation of the posttraumatic symptoms, including dissociations (if not for that day, all of this would not be happening), which lead to more posttraumatic shame and the avoidance of subsequent family meals. By using grounding techniques and self-talk about post-trauma and about the value in learning to tolerate their difficult emotions, patients become able to observe themselves, and take small steps towards a more stable daily routine.

In summary, these treatment guidelines form a conceptual model for intervention with combat veterans with severe posttraumatic disorders that is also suitable for use with veterans from non- Western backgrounds.

All 7 components are interrelated and simultaneously impact the impaired sense of self-efficacy or posttraumatic shame as well as are affected by it. It is therefore crucial that, to the degree resources allow, treatment plans should aim to reflect all components.
In our experience, a true working partnership is formed only when patients realize that all these elements are the business of therapy. Only then does the patient become actively involved in the treatment plan. Direct trauma work, using evidence-based methods, can then be pursued.

The approach suggested by this model is for therapists to have an active, direct, and authentic presence, in order to form the alliance necessary so that patients are able to engage in the difficult work of trauma-focused treatment and the retention of change over time.


Yael Caspi, M.A., Sc.D.
Clinical Psychologist
Director, Veterans' Outpatient Services Department of Psychiatry
Rambam Medical Health Care Center