Israel’s existing mechanisms for finding and treating veterans coping with post-traumatic stress are woefully inadequate due to a notoriously invasive and byzantine Defense Ministry bureaucracy, structural issues that prevent people from requesting help they need, and generally ineffective treatment options.
Those issues came to the fore this week after 26-year-old Itzik Saidyan, a veteran of the brutal battle of Shejaiya in the 2014 Gaza war, dowsed himself in a flammable liquid and set himself on fire outside the offices of the Defense Ministry’s Rehabilitation Department in Petah Tikva, roughly 24 hours before the country brought in Memorial Day.
Saidyan remains in critical condition with burns over his entire body as of Wednesday afternoon, with doctors fighting to save his life in Sheba Medical Center in Ramat Gan.
Saidyan’s apparent protest prompted a flurry of statements of support for him and his family, as well as calls for action by politicians and activists to address the ministry’s methods of treating veterans struggling with post-traumatic stress.
A comprehensive solution for the issue would be no simple task and would require major overhauls not only in the military and Defense Ministry’s protocols, but in society’s understanding of trauma and the effects of combat service on soldiers’ brains.
“There is a lot of ‘black and white’ thinking about trauma. If you come out of the military and you’ve been through a lot of stuff, either you have PTSD or you have nothing. That is the idea. But the reality, of course, is that it’s a continuum,” said Danny Brom, the founding director of Metiv: The Israel Psychotrauma Center, which treats people suffering from PTSD. (Full disclosure: This reporter’s wife is the director of research for Metiv.)
Not everyone who goes through a traumatic event or events will develop full-blown post-traumatic stress disorder, a condition that typically includes intrusive, recurring flashbacks, hypervigilance, avoidance of triggers, and varying emotional symptoms, like anger or depression.
Some people may only develop a few less-intense symptoms, which they may not even realize come from post-traumatic stress: avoiding sitting with their back toward a door, difficulty sleeping, or increased drug and alcohol use.
Others can have no lingering adverse reactions to trauma.
“When you go through trauma, people say you need treatment. But in my experience, people are able to cope with a lot of shit that’s happening in the world. Some people need treatment, others don’t,” Brom told The Times of Israel over the phone on Wednesday.
But finding those people who do require treatment and actually getting them the care they need can be difficult.
Though Israel Defense Forces officers can proactively bring in mental health professionals to speak with soldiers following a traumatic event, this is not a standard or required practice. And while there is increased awareness in the IDF and the Defense Ministry about post-traumatic stress, the current systems depend overwhelmingly on soldiers and veterans seeking out help themselves from the military’s Combat Stress Unit or the ministry’s Rehabilitation Department, rather than either of them actively providing it to veterans.
Not getting help
As of December 2020, some 5,000 people are recognized by the Defense Ministry as suffering from post-traumatic stress disorder, roughly 200 of them veterans of the 2014 Gaza war — a number that is likely far, far lower than the actual number of veterans with the condition.
A 2018 study, conducted by the IDF itself, determined that of the soldiers who participated in fighting during the 2006 Second Lebanon War, only 2.19 percent sought treatment for post-traumatic stress from the military or Defense Ministry in the seven years following the conflict, while the actual estimated prevalence of post-traumatic stress was between 3% and 11%.
According to Brom, who has been researching trauma and PTSD since the 1980s, this gap is not particularly surprising as one of the main symptoms of post-traumatic stress disorder is avoiding triggers, making it less likely that veterans will turn to the military — a major potential trigger — for the help they need.
“Going back to the army to get treatment is almost a contradiction,” Brom said.
Moreover, while the military’s Combat Stress Unit, which operates a clinic out of Sheba Medical Center, is easily open to any former combat soldier or soldier who saw combat without the need for a PTSD diagnosis, the Defense Ministry has far more demanding criteria.
In order to receive assistance from the ministry’s Rehabilitation Department, a veteran must file a request with documentation showing that they have PTSD and that the condition stems directly from their military service. As the normal cut-off time for such requests is three years, this can be particularly difficult for veterans whose symptoms develop several years later, a common occurrence.
In the case of Saidyan, he was recognized by the Defense Ministry as having post-traumatic stress disorder in 2018 and was documented as being 25% disabled, entitling him to certain government benefits. For years, he has been fighting to be recognized as being 50% disabled, a status that would award him greater assistance from the Rehabilitation Department, but his requests were denied twice, according to the ministry.
That bureaucratic system is just hell. It’s just unbelievable what happens there
In part, the Defense Ministry’s evaluation committee determined that a portion of Saidyan’s disorder came not from his military service, but from traumatic events in his childhood, thus making him ineligible for recognition from the Rehabilitation Department.
While efforts have been made to assist in this process, the Defense Ministry bureaucracy is infamously frustrating to navigate and, at times, almost antagonistic toward veterans seeking help. People making requests have to forfeit their right to privacy and allow the ministry open access to their entire medical and educational histories. The ministry has even been known to use private investigators to look into the backgrounds of applicants.
“They not only went through the wars and what they did and what they’ve seen, but then they’ve gone through the system of the Defense Ministry. That bureaucratic system is just hell. It’s just unbelievable what happens there,” Brom said, based on discussions he’s had with veterans who have been through the process.
Those practices have led to Knesset hearings, as well as a parliamentary subcommittee dedicated to improving the country’s treatment of veterans suffering from PTSD, led by MK Ofir Sofer of the Yamina party, who has personally dealt with post-traumatic stress symptoms.
“The state is suspicious of its soldiers, that they are making things up. We are talking about soldiers whose injuries are well understood,” Sofer said at a subcommittee meeting last September.
Following Saidyan’s self-immolation, Defense Minister Benny Gantz and Defense Ministry Director-General Amir Eshel called for an internal investigation of the Rehabilitation Department, the initial findings of which were ordered to be presented within the coming days.
“This is a shocking and extremely difficult event. It is the responsibility of the Defense Ministry to fulfill the State of Israel’s moral obligation to treat and rehabilitate those who are sent to defend it, and we are determined to bring about a meaningful change,” Eshel said in a statement.
Removing the stigma
In the place of the IDF’s Combat Stress Unit and the Defense Ministry’s Rehabilitation Center, two large non-governmental organizations have stepped in to provide treatment to veterans: The Natal Israel Trauma and Resiliency Center and Brom’s Metiv. In addition to these two NGOs, each of which treats thousands of people, there are a host of smaller groups providing a variety of treatment and support options to veterans, often for former members of particular military units.
Yet barriers remain, preventing veterans from getting help, including social ones.
“Israel has a long history of denial, of being strong, of functioning and of not relating to [trauma],” Brom said, noting that it wasn’t until 1987 that the first organization specifically aimed at helping Holocaust survivors was formed in Israel.
Brom, who moved to Israel in 1988, said there has been a shift in thinking recently on that front, removing some of the stigma from PTSD and related conditions.
“The trauma label makes it easier for people to seek treatment, once there’s awareness. It doesn’t have a title of mental illness. It’s something outside of you, that you’re the victim of,” he said.
Brom’s organization seeks to make it easier for veterans to get treatment by offering their programs not to those who have post-traumatic stress specifically, but to entire units that have gone through a traumatic event.
The trauma label makes it easier for people to seek treatment, once there’s awareness. It doesn’t have a title of mental illness. It’s something outside of you, that you’re the victim of
Metiv’s program, called Peace of Mind in English and Masa Shichrur, literally “release journey” in Hebrew, takes these units out of the country entirely — believing it necessary to remove the trigger of being in Israel — to a Jewish community abroad for a week-long intensive workshop, in addition to shorter sessions in Israel.
By opening its program to all veterans who have been through a traumatic event, not only those who actively seek care, Metiv has found that a larger percentage, 15%, ultimately do seek treatment.
When help doesn’t help
One fundamental problem with treating PTSD and related conditions that affects not only Israel but every country around the world is this: Most treatments are ineffective.
“We’re not in a good place,” Brom said.
A recent review of existing evidence-based treatments from 2015 found that only about a third of all patients recovered from military-related PTSD.
But he is not disheartened.
“We need to see if there are better approaches to get better results,” Brom said.
One area showing promise is the use of MDMA, more commonly known as the drug ecstasy, as part of a psychotherapy framework, which has been shown to have a much higher success rate than many existing therapies.
For Israel, Brom envisions a much more holistic approach to helping veterans. “In that model, we basically take responsibility for someone who comes out of the army until he is in a good place,” Brom said.
That means recognizing that combat service requires people to fundamentally change the way they think, literally altering their brains, a process that can take time to reverse, where things aren’t “kill or be killed,” where a boss isn’t a commander.
You need your brain to function differently if you are going into combat, but if you do that for years, it’s not so easy to change that back,
“We have to realize that there is a price to combat service. That is not psychopathology. You need your brain to function differently if you are going into combat, but if you do that for years, it’s not so easy to change that back,” he said.
“Society has to make sure that when you get out of the army, you really get out of the army. That has to become a norm,” he said.
While Brom is hopeful that Saidyan’s tragic story will prompt more veterans to reach out for care — indeed Natal has seen a three-fold increase in the number of calls it receives following Saidyan’s self-immolation — he is doubtful that it will prompt the fundamental, comprehensive change needed to help IDF veterans.
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