You, me and the never-ending war
Like a virus, post-traumatic stress can spread through the families of victims. The fifth chapter in Shomrim’s Cloaked in Trauma series is dedicated to the secondary victims - the parents, children and siblings of PTSD sufferers, whose lives have changed beyond recognition by the condition and who are at higher risk of developing symptoms themselves.
Photos: David Rubinger - GPO, Asaf Einy, Shlomi Yosef. Image processing: Noam Tamari
October 12, 2020
s a child, Shiraz Greenbaum couldn’t understand what was wrong with her father, a victim of PTSD from the Yom Kippur War. Her mother had the same problem. "My mother met my father after the war, when he was still okay," Shiraz says. "It didn’t manifest in him right away. His instability started when I was about three years old. It was only much later that I found out he had tried to commit suicide several times after the war."
And only much later, too, did she discover the source of her father’s trauma, as related to her by one of his friends: In 1973, her father, Michael Greenbaum was serving in the Shaked reconnaissance unit. He fought in the Battle of the Chinese Farm - a three-day clash between Israel and Egypt, in which both sides suffered heavy losses. After the battle, he spent 48 hours removing the bodies of his fallen comrades from the Sinai dunes.
Shiraz’s childhood home, as she experienced it, was a dysfunctional space. "There was always a tense vibe, fits of rage, and alcohol abuse," she recounts. "My father worked as a lighting technician and cameraman on movie sets and was often away from home. I think something about the intensity of the work and the effort to exhaust himself are connected to the post-trauma. He’d disappear from home and then reappear all of a sudden. I remember a lot of yelling, a lot of chaos. He was prone to severe mood swings, crying and depression."
Her parents divorced when she was nine, and at 12, she and her mother moved from Tel Aviv to Zichron Yaakov to get away. "I don't remember him coming to any ceremony at school or in the army," she says. "I couldn’t invite him. I remember asking him not to drink on my birthday, and I kept asking him to be okay and I knew it wasn’t going to happen. Before the age of 16, I didn’t hear a thing from him about his army experience. And then I went to visit him one day, and he was a complete wreck; he started telling me things about the dunes, about friends and about the reconnaissance unit. I realized he was talking about the army, but I couldn’t put two and two together; I didn’t have a name for it."
At 25, Greenbaum - now 40 and working as a photographer, photo editor and social activist - decided to give it a name, and she renewed her relationship with her father. "I moved into a place on my own and decided that I have to solve the problem," she says. "I invited him to my birthday party. He turned up drunk and embarrassed the hell out of me. He must have sensed it and he called me after that night and told me he was going into rehab. I realized then that he was in therapy. And that was the start of a long and painful process of rebuilding trust. And there was still a feeling that he could disappear in an instant - or I could."
In 2004, 31 years after the Yom Kippur War, Shiraz’s father was recognized as a victim of PTSD, and the pennies started dropping for her too. "And they continue to do so all the time," she says. "I’ve been dealing with the intergenerational transference of trauma ever since I came to grips with my father’s ‘problem.’ I set out on this journey to understand my father and how it has affected me. I got to know his friends. And I realized suddenly just how much it impacted on me. There’s something about experiencing trauma that makes you feel like everything you have could be lost at any given moment.
"I talk these days with friends of my own age whose fathers suffer from PTSD, and I’ve come to realize that it manifests itself in many, many ways. I have friends who suffer from severe sleep disorders, with anxiety, who shut themselves off and avoid social situations. The children of victims of PTSD don’t have a full set of tools when it comes to understanding their situation. I also, grew up with the constant sense that I don’t really know who I am. There was a lot of depression and anxiety; a feeling of very basic insecurity in the world; issues with intimacy and the ability to forge relationships. Having had a father who was constantly coming and going led to a great deal of dysfunction in my relationships. I think that because I spent so much time with my father from the age of 25 onwards, I began to see all of these transferences."
Like cancer, PTSD spreads
After focusing on the consequences of the ongoing trauma in the Gaza-border communities, as well as military-related PTSD that manifests itself in the third age, we’ve chosen to turn our attention in this, the fifth chapter of Shomrim’s Cloaked in Trauma series, to family members of victims and to shed some light on their difficulties and distress, and how PTSD implants itself deep within the family.
In Israel, a pressure pot of terror and hardship that creates PTSD on a regular basis, an estimated 16-20 percent of soldiers who are exposed to distressing combat situations will develop symptoms of post-trauma. The implications for their family members, however, remain a painful and largely unnoticed issue in Israeli society and certainly don’t get the recognition and attention they deserve. For many years, therapy has focused exclusively on former soldiers with PTSD; the same goes for the academic research surrounding the issue.
Over time, this research, in Israel and around the world, did indeed expand, but it dealt primarily with the spouses of PTSD victims only. And this, too, according to Israel Prize laureate Prof. Zahava Solomon, a world-renowned scholar in the field of traumatic stress from the School of Social Work at Tel Aviv University, was a struggle initially to get off the ground. In the 1980s, when Solomon served as head of the Research Division of the Israel Defense Forces’ Mental Health Department, she wanted to conduct a study on the wives of PTSD sufferers.
In Israel, a pressure pot of terror and hardship that creates PTSD on a regular basis, an estimated 16-20 percent of soldiers who are exposed to distressing combat situations will develop symptoms of post-trauma.
Solomon’s proposal, as she recalls, encountered a great deal of cynicism and skepticism, with one of her commanders responding thus: And what’s the next project? Cousins? Why drag wives into all this? We don’t have the budget or resources to handle the men, and now you want the wives too?
"No one thought of trauma as something that creates a circle around itself, and to be fair, not much was known at the time about the circles of trauma," says Solomon, who managed eventually to secure a budget from outside the military and kickstart her research.
The increase in the research about the wives of PTSD victims led to a greater understanding of the distress faced by spouses, the heavy burden they carry and how they, too, are affected by their partners’ conditions. At the same time, critical familial circles were left, to a large extent, by the wayside. These include (at the very least) the children of PTSD victims, their parents and their siblings - entire generations that received no therapy, were never diagnosed, and have never been offered any assistance.
Testifying in 2010 before the Goren Committee, which was set up to examine the criteria for eligibility for financial assistance from the Defense Ministry, Solomon likened post-trauma in the family to metastatic cancer. "During my interviews with wives," she noted, "I often had to ask myself why they stay. Life in such families is very difficult and extremely complex. And what happens to the children? Not only is the cancer metaphor valid; it’s also a fact that it crosses the biological barrier. What happens to a child who grows up in a family in which the father suffers from PTSD first hand, and the mother suffers second hand? In some of the interviews, we were faced with extreme conflicts concerning an immediate call to the welfare authorities and what should be done with the children in such families."
Prof. Rachel Dekel: "There are several excellent and creative therapeutic solutions for people who have experienced a traumatic event, but the family perspective is lacking. You have to remember that victims spend most of their time with their families and not in therapy, and we still have a long way to go as far as that’s concerned."
And indeed, the distress levels of children to fathers with PTSD are almost four times higher than among the general population, according to a study into the effects of traumatic events on direct victims and their families led by Prof. Rachel Dekel, a senior researcher at the Bar-Ilan University’s School of Social Work. The study involved 46 adult children (over the age of 20) and was the first in Israel to examine the long-term consequences of life alongside a father suffering from PTSD from the Yom Kippur War. Published in 2008, the findings showed that in terms of each of the criteria - anxiety, depression, interpersonal sensitivity - the children of PTSD victims expressed significantly higher levels of distress than the members of the control group (children of Yom Kippur War veterans who weren’t left emotionally scarred), and a diminished capacity to cope with stressful situations.
The study described family life as frequently accompanied by anger and aggression, and occasional incidents of violence. Children are often exposed to withdrawal on the part of the father from involvement in family life. The father’s parenting patterns are often characterized by strictness, emotional distance and overprotection. The capacity for intimacy in relationships among the children was also found to be lacking, and these signs of distress are evident even after they’ve left home and entered adulthood.
"There are several excellent and creative therapeutic solutions for people who have experienced a traumatic event, but the family perspective is lacking," Dekel says. "You have to remember that victims spend most of their time with their families and not in therapy, and we still have a long way to go as far as that’s concerned. Research has shown that the victim’s significant others are also affected. At the same time, as proven in numerous studies, social support from someone close is a very significant resource. So, on the one hand, family members are exposed to daily life with a victim, and on the other hand, if we give them the help and support they need, and teach them just how extensive manifestations of PTSD within the family can be, they can serve as a source of support. If we can promote this idea and a general understanding that trauma exists within the family, maybe we’ll be able to affect a change."
Confirmation of this intergenerational transference of trauma can also be seen in the findings of Prof. Gadi Zerach, a clinical psychologist and associate professor in the Department of Behavioral Sciences and Psychology at Ariel University, who conducted a study involving the children of released POWs from the Yom Kippur War. Zerach’s findings, together with Solomon’s, have given rise to a fascinating longitudinal study: Since 1991, Solomon has been following the lives of released POWs, a significant proportion of whom suffer from PTSD, while Zerach conducted a study involving around 100 of their adult children, aged 30 to 35. The resulting complementary research picture - the fathers’ reports alongside those of the children - reflects the extent to which victims of shell shock don’t live in a vacuum.
Prof. Gadi Zerach: "often the children can identify so strongly with the experience that they, too, can develop the same symptoms. In other words, the children, to some extent, pay a price for the love for their father and their empathy, but in the process, they also identify with the fragility, the outbursts and the lack of emotional regulation."
"We found that children of post-traumatic parents report more psychological and behavioral problems than children of parents who fought in the Yom Kippur War and weren’t captured, or children of released POWs who don’t suffer from PTSD," Zerach says, noting that "we belong to a large group of researchers around the world who, for more than a decade, have been saying that post-trauma has far-reaching implications for the family. It has an adverse effect on almost all familial ties, as well as the emotional state of the people closest to the sufferer. Today, the DSM-5, the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, also recognizes the possibility that a family member of an individual with PTSD is likely to be diagnosed with the same."
Did you find a connection between the emotional state of fathers and their children?
"We found a consistent and distinct connection between the father’s emotional state over many years and the emotional state of the adult child. Specifically, we saw that adult children report post-traumatic symptoms themselves, such as avoidance, anxiety, depression and emotional insensitivity. In the study, we refer to this as secondary traumatization."
What does the parenting look like, as shown by the study?
"Many of the fathers reported difficulties with parenting, difficulties in terms of closeness to their children, being sensitive to their needs, and cooperating with them. We saw that the captivity itself wasn’t the mediator of the severe effects on parenting, but rather the post-traumatic symptoms themselves. The father opts sometimes for avoidance and he’s distant, and sometimes he’s more impulsive, short-tempered and incomprehensibly angry. And often, the children can identify so strongly with the experience that they, too, can develop the same symptoms. In other words, the children, to some extent, pay a price for the love for their father and their empathy, but in the process, they also identify with the fragility, the outbursts and the lack of emotional regulation."
Shalev Doron: "I was armed with a MAG. I think I hit the terrorists; it was from a distance of 300 meters and without earplugs. I saw my friends being killed and also my enemies. Since then, noise is something that I struggle with a lot. Every time I hear an airplane, I cringe, my body readies itself."
The children in the study also reported higher levels of parental absenteeism and inaccessibility, and less secure ties with their fathers. "Studies we’ve conducted," Zerach explains, "show that having a father who is often present physically but not psychologically seeps into the children’s self-experience, becomes a more fragile feeling and affects the boundaries of the self. This is the tragedy of the lack of closeness; fathers who try to distance themselves from the traumatic experiences as part of their coping also distance themselves from their children. This distancing can turn into a significant difficulty for the children, who can’t understand why their fathers can be colder and more distant."
Do they look for answers elsewhere, from others?
"A large part of the damage to the relationship stems from the fact that the father’s experience is obscure and incomprehensible. It turns into snippets of information that come from others and the media. From a psychological perspective, the information is often unprocessed and becomes offensive and dangerous. The children experience something very intense in their contact with their fathers, but can’t understand it at all."
"Students approach me sometimes after a lecture on the subject and say: ‘Now I realize where I grew up, what I had to deal with at home. We didn’t read, we didn’t understand’," says Prof. Dekel. "In other words, sometimes the parent isn’t defined as post-traumatic, and some children can’t put a label on their parents’ distress."
According to Dalia Yosef, the director of the NATAL (Israel Trauma and Resiliency Center) helpline, "Some of the children of PTSD victims only seek help when they become parents themselves. They start to see signs of difficulties in their relationships and outbursts of anger with their children. It reminds them of patterns of behavior from their childhood and they say to themselves: I do not want to be such a parent. I want to be a better parent. And then they ask for help."
"As a parent, you need to change your thinking"
One family whose lives have been turned upside down in recent years is that of Shalev Doron, 25, a Golani Brigade fighter who participated in Operation Protective Edge and was recognized last January as a victim of PTSD. Shalev, and his mother, Ahuva, his father Chasdi, and his twin sister, Noga, recount the painful process that led to the diagnosis, how it affects the family, how they’ve had to get used to a "different" son, a "different" brother, and what it all looks like from the sober and sensitive perspective of Shalev himself.
"It started one day in July 2018," Ahuva recalls. "At some point in the afternoon, Shalev yelled at me, which was very out of character. I got a huge fright. The next day, he called me at work in the afternoon and asked me to come home immediately. I was terrified. I went home and he was sitting in the living room, a 23-year-old guy, and he told me he’d been crying for four hours. I didn’t have the tools to deal with it. I didn’t know what to do. All he said was that he felt very sad, and didn’t elaborate. I suggested he go to see the family doctor. He spoke with her for an hour and a half and she advised him to seek help through a mental health clinic."
Shalev: "From there, I went to my job at the pub. My boss took one look at me and said: ‘You don’t look well.’ I had my first attack during that shift; I was bathed in sweat; I broke the door in the pub’s bathroom."
Ahuva: "The following day, he started stuttering and developed an involuntary twitch in his face, uncontrollable spasms. I remember looking at my son, astounded; what’s with all those spasms? We were sure he was having a stroke, that it was a neurological problem."
It wasn’t a neurological problem. Rather, the events of July 2014, which erupted violently after four years of virtual dormancy. "Operation Protective Edge is an ongoing experience for me," Shalev shares. "I lost a friend every day. I’d hear about it via text messages or rumors. Little by little, you become more indifferent. One day, we were sent to an assembly point near Gaza. Mortars were raining down on us nonstop. I was part of an ambush and then I also heard about the casualties, the dead and wounded from the 13th Battalion, my battalion. I was dehydrated. We went back to the outpost and they hooked me up to an IV. I had a fever. When I woke up, we heard that there were 10 terrorists at the fence.
Shiraz Greenbaum and her father Michael: "I’ve been dealing with the intergenerational transference of trauma ever since I came to grips with my father’s ‘problem.’ I set out on this journey to understand my father and how it has affected me. I got to know his friends. And I realized suddenly just how much it impacted on me."
"I was armed with a MAG. I think I hit the terrorists; it was from a distance of 300 meters and without earplugs. I saw my friends being killed and also my enemies. Since then, noise is something that I struggle with a lot. Every time I hear an airplane, I cringe, my body readies itself."
"It takes a long time to realize that PTSD is unlike anything you know. It requires understanding. As a parent, you have to change your thinking," says Shalev’s father, Chasdi, with his mother adding: "To realize he’s not the same boy and that there’s no point thinking that he’ll be back. To realize that there’s no turning back the clock and that you have to move forward. To realize he’s not going to be a structural engineer."
Shalev: "Family life changes after such a thing. All of a sudden, they feel like their tiptoeing through a minefield when they talk to me. They don’t know what’s going to set me off, and I do explode. You don’t meet your own demands either. It’s very tough - like being unable to understand why I can’t leave the house. And how do I explain it to my parents? They’re also my moral role models."
Ahuva: "Your son’s there in front of you, coughing, vomiting, stuttering, suffering and you can’t do a thing. It was very difficult in the beginning to go out walking with Shalev. He has vocal tics; he falls. There’s an element of uneasiness until you get used to it."
Shalev: "Being disabled is hard work."
Ahuva: "Being the mother of a disabled child is hard work."
A positive side-effect: Post-traumatic growth
"It's not a scar. It's an open wound for life. When it happens to me, it could leave a scar. When it happens to a child, it's an open wound for life. And that’s it. It undermines all confidence, unsettles life completely." Those are the words of one father whose son suffers from PTSD, who took part in a study conducted by Neta Levavi of Bar-Ilan University, in collaboration with NATAL and under the guidance of Prof. Rachel Dekel. The study involved 14 parents of men under the age of 30 - all suffering from PTSD following their military service.
Levavi writes in her study that parents experience "great distress in the face of the therapy and being around their adult children, so much so that in many cases, they’ve experienced the trauma of the children as their personal trauma. Here, too, we see evidence of the symptoms spreading. We found a distinct correlation between their descriptions of what they experienced and the different groups of symptoms of post-traumatic stress disorder - aggressiveness, avoidance, negative mood swings and cognition, as well as hyperarousal."
And what about siblings? Noga, Shalev’s twin sister, for example, says that the sensitivity to noise from which her brother has suffered since the incident during Operation Protective Edge has migrated to her too. "Shalev struggles a lot with noises, and it’s become a thing for me too," she says. "I’m very scared of loud noises, which trigger harsh reactions in me. Someone screamed one day during a class at Bezalel and my whole body tensed up and I burst into tears in front of everyone. I also live near the Prime Minister’s Residence and I hear police sirens all day. I didn’t used to have this sensitivity."
Sensitivity to noise has become a family issue. When I arrived at the family home in Pardes Hannah to conduct my interviews, Ahuva asked if I could hear the noises from the nearby military firing range. I couldn’t hear a thing. Shalev could hear them clearly, as could his mother, who says she never noticed the noise before her son’s post-trauma.
"Shalev’s post-trauma greatly affects me and the family dynamic," Noga says. "It’s such an ever-present kind of post-trauma, because of its side effects, and you have to get used to it. It comes with a lot of pain, vomiting, moaning and groaning, as if someone’s hurting him. It’s hard to listen to. You really want to help and there’s no way you can. There’s a great deal of helplessness, and it’s frightening too. It’s not something you can put aside and think about later. It’s with you all the time and very present in my behavior. There’s a lot more concern in terms of looking after him, even if he doesn’t want it. As I see it, Shalev’s condition isn’t getting better; I think it’s getting worse. He’s lost a lot of weight, he smokes a lot, and he hardly sleeps. It’s very hard for me to understand sometimes why the therapy isn’t working. I can’t see things getting better for us in the future, but Shalev is a very strong guy and maybe he’ll be okay, just a different or new kind of okay. But I’ll have to get to know him first, before I feel that he’s okay."
Zerach says that to the best of his knowledge, there are no other studies focused on the siblings of victims of military-related PTSD. A new study he led, however, found a distinct correlation between the emotional state of a veteran fighter and his post-trauma symptoms and the emotional state of a sister or brother.
The study involved 106 dyads of combatants who were discharged from the military in the past decade and their siblings, those closest to them in terms of age. "We handed out questionnaires on secondary post-trauma symptoms to the siblings and we asked how their emotional experiences are linked to the military service of their brothers who were involved in combat. Approximately 4 percent of the siblings reported post-traumatic symptoms that crossed the clinical threshold in this regard. In other words, they have secondary traumatization. However, the positive correlation indicates that among the sample as a whole, too, post-traumatic symptoms of former combatants are linked to an increased chance of psychological distress among their siblings, even if it doesn’t cross the clinical threshold."
Alongside the coping difficulties, the study also addresses secondary post-traumatic growth; that is, the ability of family members to grow as a result of the trauma and not just survive it. Among researchers, by the way, opinions are divided as to whether this is indeed a phenomenon or an illusion. Zerach has his own conclusions from the sibling study: "We found an interesting effect: If siblings have secondary traumatization, they do indeed suffer more, but they are also more likely to develop post-traumatic growth, to speak about higher levels of emotional learning and psychological development as a result of these experiences."
Noga, Shalev's sister, reinforces these conclusions and says that the post-trauma strengthened what was already a good relationship with her brother. "We talk a lot and very honestly about a lot of things. We no longer quarrel or get upset about the usual things that brothers and sisters without problems do. Shalev has become very open to things, very sensitive, more understanding, and much more tactile."
Shiraz Greenbaum, with whom we began the article, also wants to end on an optimistic note. She’s currently managing an online Hebrew-language forum for children of PTSD victims, which includes an open invitation to join a therapy group as well as information on the intergenerational transference of trauma.
"Today, after years of effort by both of us, my dad is in good shape and is more in touch with friends and family," she says. "My parents are in touch again after 30 years and they meet occasionally. We’ve gone back to being father and daughter, with me now 40 and him 70. He looks out for me, offers wise advice. The process definitely paid off in the end. I feel today that I have a father."
Secondary trauma: Genetic or viral?
Secondary traumatization is one of the most significant and researched issues that occur in the families of post-trauma victims. To put it simply, secondary traumatization is a form of infection, with post-traumatic symptoms passed on to family members via a mechanism that studies have yet to fully decipher. It is often described as a mechanism similar to contracting an infectious disease.
"One explanation is behavioral; there’s a process of learning and internalization here," says Prof. Gadi Zerach of Ariel University. "If I, for example, hear repeatedly that a certain thing is very dangerous, I’ll start to be wary of it and sensitive to it. The same goes for a mirroring process; the child, for example, mirrors the avoidance of the father."
A second explanation, he continues, is emotional, "because of the significant emotional closeness, and often we are talking about people who constitute role models for us; we observe them all the time and begin to experience things as if they are ours."
Another explanation is the genetic explanation, which is based on research findings that point to genetic factors in the development of post-traumatic stress disorder. According to this model, vulnerability to post-trauma is inherited, and children with the syndrome, therefore, are at higher risk of developing distress in response to stressful events in their lives.
Alongside this explanation, there are also studies on epigenetic influence: Heritable phenotype changes that do not involve alterations in the DNA sequence but in the function of genes and stem from environmental influences. "The very fact that from a young age, the child hears harrowing stories or witnesses harsh behavior on the part of the father could perhaps sharpen or activate something in terms of his or her sensitivity to anxiety," Zerach says.
"Family members," notes Prof. Rachel Dekel, "report dreaming about the battlefield, nightmares, and even flashbacks related to incidents that occurred while in captivity - even though they weren’t physically there. The family member develops PTSD-like symptoms or is infected with them, and becomes, for all intents and purposes, a victim of the trauma itself."
Dekel, who runs an intervention clinic at Bar-Ilan University for couples dealing with PTSD in one of the two partners, says they’re now looking into an intriguing question - the possibility of physiological infection. "We’re interested in the physiological dynamics between the couple," she says. "When the post-traumatic man experiences symptoms - increased sweating, an increase in heart rate and blood pressure - what happens to his partner? Do her physiological signs increase too? Or do they decrease and she disconnects? Or is the pattern different and her signs increase only to a certain level so as to help him and, together, lower the level of physiological distress?
"Research around the world on this subject is partial only; for example, a study in the United States showed that the level of arousal during conflict is higher in the wives of the PTSD victims; it’s as if the PTSD is under their skin, in their blood."
A relevant finding worth noting in this context emerged from a study conducted by Dr. Tzachi Ein-Dor and Prof. Zahava Solomon: The risk of developing signs of secondary trauma among wives of released POWs with PTSD was 21 to 50 percent higher than the risk among spouses of fighters who did not develop PTSD.