Cloaked in Trauma
The Balloon Will Eventually Burst
The number of trauma victims in the Gaza border area communities has doubled in the past two years, but the general public, elected officials, and even government institutions do not seem to be interested or impressed. What is the reason for the overall lack of interest and apathy about life in the Gaza border area? Could this be the reason for the increasingly deep cracks in the resilience of the residents - a resilience for which they are so well-known?
Gaza border area | Photo: Jonathan Bloom
September 17, 2020
ollowing a period of relative calm after 2014's Operation Protective Edge, the past two years have been very turbulent for residents of the Gaza border. In some cases, it has been just too much to handle. The clashes on the border between the Israel and Strip terrorists have included cross-border attacks, Qassam rockets, tunnels, explosive kites and balloons, and sirens sounding at all times of day and night. The number of anxiety victims has shot up accordingly. In 2019, the resilience centers in the Gaza border area treated 4,348 anxiety victims, almost double the number the previous year.
When laconic news bulletins on rocket attacks conclude with the words "There were no injuries and no damage," many locals are irate. Almog Boker is a news reporter for Channel 13 TV and a resident of the Gaza border area. During the most recent escalation, he initiated a change in the reporting terminology. His station now reports that "no one was physically injured, but there are some psychological injuries."
According to Talia Levanon, director of the Israel Trauma Coalition, which operates the six resilience centers in the Gaza border area, "The escalation in the south since March 2018 totally changed the scope, the numbers, and the manifestations. It brought huge changes in the symptoms of trauma sufferers. We are now seeing new and more severe emotional disabilities; the number of people we refer to psychiatric treatment is increasing, and more people are taking medication"
The residents of the Gaza border area have long been furious with the government for its impotence and with politicians and the public for their indifference. They feel unseen by the rest of Israel. They argued that there are two Israels: The Gaza border area and the rest of the country. They note the issues that have galvanized the entire county - from the social protests in the summer of 2011 over the high cost of living to the campaign to release Na’ama Issachar from jail in Russia and, most recently, the coronavirus epidemic. Even when the entire country is united in an apocalyptic emergency situation, it seems that the residents of the Gaza border area still feel different since they are very familiar with emergency situations, a closed-down educational system, and the sense of perpetual threat.
The number of anxiety victims has shot up accordingly. In 2019, the resilience centers in the Gaza border area treated 4,348 anxiety victims, almost double the number the previous year.
On social media, some of the residents have expressed the hope that "the day after the coronavirus, people will no longer say that we are insignificant, now that everyone has experienced what our daily existence is like." Another resident wrote: "When it’s all over, Israel will recover from this crazy epidemic that hit us and everything will return to normal, to the wonderful period when the entire country was quiet and strong, except for that region down there …what’s it called again?…ah, that area where they have been living with this kind of reality for the past 20 years but the prime minister has not gone live on national television every evening, not even one evening, to deliver an address to the nation about how the crisis is being managed."
According to Prof. Zahava Solomon, a researcher of psychiatric epidemiology in the School of Social Work at Tel Aviv University and an Israel Prize laureate for the study of social work, "the situation in the south proves the existence of something that we never thought would happen in Israeli society: The Jounieh Syndrome." While the rest of Lebanon was being torn apart by a bloody war with Israel in 1982, the holiday town of Jounieh continued to party.
"You cannot expect everyone to put their lives on hold every time a rocket or explosive balloon falls in the south. But this creates a kind of dissonance; it’s as if there are two countries in Israel. If there is an event that affects only one of them, then, all the solidarity in the world cannot help to heal social rifts."
According to Prof. Zahava Solomon, an Israel Prize laureate for the study of social work, "the situation in the south proves the existence of something that we never thought would happen in Israeli society: The Jounieh Syndrome." While the rest of Lebanon was being torn apart by a bloody war with Israel in 1982, the holiday town of Jounieh continued to party.
Solomon stresses that, along with the indifference, there is, nonetheless, a great sense of solidarity. To prove her point, she mentions last November’s heart-wrenching post by Reut Spielman Drier from Ashkelon, which managed to pierce the collective Jounieh Syndrome armor. Drier filmed her two children trembling with fear a few seconds after the siren had sounded, refusing to leave the shelter and return home. Likewise, in February, the country was shocked to hear about Velah Digilov’s three-week-old daughter who was injured when Digilov fell, baby in arms, as she was running down the stairs to reach the shelter. Digilov told the media that her two older children "saw everything: the fall, the ambulance taking me and their baby sister to hospital. They may not have been physically injured, but they were certainly mentally scarred. This is sometimes a far more serious injury than a physical one."
The Health Ministry's estimates for last year are that only 3 percent of the residents of the Gaza border area apply to the National Insurance Institute to be recognized as victims of terror attacks as a result of their emotional trauma. The table below shows the number of civilian terror victims suffering from PTSD or other mental problems (excluding IDF victims who are recognized by the Ministry of Defense). When we asked the Health Ministry for figures relating only to residents of the south, the spokesperson told us that "we are unable to analyze data according to place of residence."
One way or the other, there is no doubt that the figures represent only a partial picture of what is actually happening in the south. For example, in 2019, 16 people were recognized as trauma victims and five as victims of emotional injury. In 2018, 62 people were recognized as trauma victims and 5 as victims of emotional injury. In 2014, the year of Operation Protective Edge, there was a spike in numbers, with 260 people recognized as trauma victims and 58 as victims of emotional injuries. And yet, we are still left with the feeling that this is only one part of a giant, multi-dimensional puzzle.
In 2014, the year of Operation Protective Edge, there was a spike in numbers, with 260 people recognized as trauma victims and 58 as victims of emotional injuries. And yet, we are still left with the feeling that this is only one part of a giant, multi-dimensional puzzle.
I asked Levanon whether the National Insurance Institute is now more aware and sensitive to the needs of the population after two turbulent years in the Gaza border area.
"Unfortunately," she says, "we have not seen any greater understanding in terms of recognizing them as victims of terror. On the one hand, the situation has dramatically improved compared to previous years. In 2008, regulations were introduced to make it easier to get recognized as trauma. Until then, if you didn’t go to hospital on the actual day of the incident, you would be given the runaround for months. The new regulations state that anyone who was involved in a security incident is eligible for up to 12 therapy sessions, and even more if necessary. Nonetheless, with more and more people being recognized as trauma victims, which necessitates continuous therapy, we are still facing a challenge."
What’s the reason for this?
"I don't have an answer based on scientific research, but I think that what we are seeing is that people who experience long-term stress and anxiety are asking to be recognized as victims of terror despite showing less acute symptoms. It’s not the same as someone from Tel Aviv who experienced an incident and is now extremely fraught. Because the people who live in the Gaza border area experience trauma over a long period of time, they know how to cope, to take it as part of daily life. So then, when they appear before the committee, the severity of their trauma is not fully evident. It’s seen, for example, in the fact that if you once worked 40 hours a week, showing initiative and being hardworking, you are now slower and people don’t expect the same from you as before. If someone suffers from post-traumatic symptoms, family members tend to forgive them. The same applies to reduced functioning; there are all kinds of phenomena that are not clinical symptoms, but the person is, nevertheless, suffering," Levanon insists.
"There is something confusing when a physician sits there assessing someone who is living in an impossible situation. There are very clear guidelines for determining percentages of disability. Finding a way to ensure that the recognition of these people as trauma victims also takes into account their long-term exposure to trauma is extremely challenging."
So, paradoxically, a woman living in Tel Aviv could be recognized faster than a woman living in the Gaza border area?
"Precisely. The woman from the south is dealing with the trauma constantly. She works and she brings up her children. Think about a 30-year-old woman who has been living with trauma for the past 15 years, who grew up in Sderot and is paying the price for the exposure. This price is not only paid by her, but also by her children, because she is not as emotionally available as a parent living in the center of the country. I am not saying that parents in the center are perfect and those in the south are not; all parents do their very best to raise their children, but the woman in the south arrives at parenthood with one hand tied behind her back because she has to deal with these issues. She is less emotionally available and has her own difficulties, and the question is what message is she conveying to her children and how will she cope in emergency situations."
National Insurance Institute’s (NII) response:
A unique case that needed reevaluating
"The National Insurance Institute pays for therapeutic treatment for residents of the south at the Resilience Centers, hospitals, mental-health clinics and other NGOs that are not part of the Israel Trauma Coalition. In accordance with the Benefits for Victims of Hostile Acts Law, the NII only covers the cost of treatment for those who have been recognized by law as victims of terror attacks. However, since the First Lebanon War (2006), and going beyond the strict interpretation of the law, and taking into account the needs of this population, the NII has taken upon itself to pay for therapy for anyone who has been exposed to terror attacks. A distinction is made between compensation and therapy for anxiety.
"Studies have shown that the ability to cope with trauma is more effective if therapy is provided immediately, and therefore the NII has adopted this policy. At first, 12 individual therapeutic sessions are provided by the NII at no cost to the client. Over time, this number has been raised to 24 sessions, and during the escalation in 2018, the number of sessions was increased to 36 for those who need it.
"The figures we have for the years 2010-2016 prove the effectiveness of immediate intervention and therapy. During these years, 8,411 people applied for treatment as a result of anxiety. The number of treatment sessions was 96,370. The NII received 379 claims from these people, 351 of which were recognized.
"Due to a wish to understand the needs of the sector of this population that has been suffering from repeated, ongoing trauma for many years, and when we noted an increase in the number of children who need therapy, the NII expanded the basket of services to include family and group therapy to help all members of the family unit cope with the trauma.
In order to be recognized as a victim of a terrorist act, the specific date of the event must be given. However, since residents of the south suffer from repeated acts of terror, they cannot necessarily pinpoint a specific date. Therefore, the NII made a concession for them, and they can report on a sequence of events that led to the symptoms.
The NII maintains an ongoing dialogue with the physicians to clarify the unique situation in the Gaza border zone and how this impacts the development of trauma in this population. The emotional distress of these residents is complex and understandable. Some of them do indeed develop PTSD, some suffer from an exacerbation of an existing disorder or from anxiety disorder, sleep disturbance and depression. Yet, there are also those who have a disorder that is not included in the accepted diagnostic criteria for PTSD that necessitate a specific event and not a sequence of events.
The case of the residents of the Gaza border zone is unique, therefore the NII convened a team of experts from relevant professional fields to reevaluate their situation. The new criteria determine that eligibility can be determined even if there is not one specific event. In many cases, post-trauma appears at a later stage, even years later and this is also seen among victims of terror attacks.
The NII is now preparing new guidelines to the effect that people who are awarded disability of up to 19 percent and require more therapy in addition to the authorized number will be permitted to continue the therapy sequence with the same therapist at the Resilience Centers.
The NII’s committee receives professional data including the professional details and description of therapeutic interventions directly from the therapist at the Resilience Center, so that even the applicant does not give all the details of what has occurred, the information from the therapists completes the picture."