Post-Trauma Versus Inter-Trauma: Living with Traumatic Stress in Israel and The United States

Abstract

The question of whether prior traumatic events increase post traumatic distress or bring about habituation to living with trauma in the general (not directly exposed) population remains unresolved. We address this question by comparing and contrasting the psychological impact of a singular trauma - the World Trade Center (WTC) attacks in the United States – with that of continual trauma- the scores of suicide bombings that took place in Israel during the second Intifada (Palestinian uprising). As such the article also contributes to the discussion of the effect of cultural differences on post traumatic emotional outcomes. Utilizing an interdisciplinary approach, we present data from empirical studies of post traumatic reactions, as well as from literary works that were produced under conditions of ongoing trauma. Based on this data, we propose that a prolonged trauma may be better defined as “inter-trauma” and not “post-trauma.” We also suggest that psychological response to trauma is not universal but rather embedded in a particular rset of cultural conditions. Future empirical studies are warranted to examine specific responses to trauma in distinct cultural and national settings and to compare and contrast the differences between them.

Keywords: Post-trauma; Inter-trauma; Traumatic stress; PTSD; Culture

Introduction

How do people respond to repeated traumatic events with no end in sight? One could suggest that ongoing trauma - a seemingly endless chain of traumatic events- would increase psychological vulnerability and reduce the likelihood of overcoming it. A meta-analysis of 2,647 studies shows that a strong predictor of posttraumatic stress disorder (PTSD), the psychiatric disorder commonly associated with trauma, is exposure to prior trauma, and that this relationship is especially strong when prior trauma involves interpersonal violence in non-military context [1]. Similarly, pre-trauma stressors are also documented as risk factors for PTSD [2].

These findings may apply to individuals directly exposed to trauma as well as to general populations living in trauma’s vicinity but not directly exposed to it. Studies have suggested that in the case of mass trauma, individuals in the general population who were not present at the traumatic event and experienced no direct impact on their life may also exhibit posttraumatic stress [3,4] These studies highlight the aversive impact of trauma on victimized communities and demonstrate that acute stress reaction is common. While the majority of individuals gradually recover, in some case stress reaction can remain chronic [5].

Other studies of populations that have been exposed to continual trauma - like the Israeli population during the two Intifadas or the British population during WWII – have found contrary results. Literature on London under German Blitz during WWII shows that despite death and destruction, no panic and a few psychiatric causalities were recorded [6]. These populations demonstrate relatively low levels of psychological distress and an extraordinary resilience in the face of ongoing trauma. Similarly, studies in Israel during the Gulf War [7] found public morale to be good, even higher than during peacetime. Alongside reports of distress, they suggest that Israelis adjusted and maintained equilibrium even when the missile threat remained.

Solomon [7] believes that “the expectation that panic would occur in large segments of society under conditions of relative helplessness to life threatening conditions” is largely a “myth of panic” (p. ix). Rachman as well concludes that there is a “rapid habituation to the intense stimulation that signaled the imminent appearance of danger” (p.23.) To counter the emphasis on the negative impact of continual trauma on general populations they introduce another concept: the accommodation factor. When the “new normal” is that of continuous trauma, they argue, people accommodate themselves to it. Even if they are more alarmed initially, they later adjust and eventually acclimate to living with trauma.

In this paper, we attempt to resolve the apparent contraction in the two sets of findings by suggesting a different conceptualization of psychological trauma than has thus far been employed. In the case of continual trauma to a general population, we claim, it is perhaps more accurate to speak of the concept “inter-trauma” than of “posttrauma” reaction; this difference, we hypothesize, is at the heart of understanding the psychological effects of living with continual trauma.

In order to demonstrate our ideas, we compare two cases: the psychological impact of a singular trauma - the WTC attacks in the United States - and of a continual trauma- the scores of suicide bombings that took place in Israel during the second Intifada. By way of comparing and contrasting the two cases, we also consider cultural differences in impacting the response to trauma in a given national community; we should note that our focus is on the impact of these events on the national community at large, not on directly exposed individuals. This focus remains relatively understudied.

The Case in the United States

Following the immediate aftermath of the September 11th terrorist attacks, a body of studies revealed substantial post trauma distress among Americans, even among those who were not directly affected by the attacks [4,5,8]. According to two national surveys, 44% of all Americans were suffering from at least one or more PTSD symptom in the immediate aftermath [4]; and 17% continued to endorse stressrelated symptoms at two months post-attack. Among residents of Manhattan the majority of whom were not exposed directly to the attacks, the prevalence of probable PTSD and depression was estimated at 7.5% (approximately 67,000 individuals) and 9.7% (approximately 87,000 individuals), respectively, as far as twomonths post-event [9]. An ongoing sense of threat may contribute to the enduring of symptoms [10]. Elevated use of mental health services and psychiatric medication was reported in the New York Metropolitan area [11] and a substantial number of individuals in the New York City Metropolitan experienced probable PTSD and sub-syndrome PTSD at one-month post-event, although eventually symptoms declined [5]. Taken as a whole, these findings suggest that in the immediate aftermath of a large-scale trauma substantial psychological morbidity in the population may be evident and may extend to individuals in the general population [2,5].

The Case in Israel

In contrast to the surge of research following the events of September 11th, 2001, the study of the impact of terrorism among the general population following the Second Intifada in 2002 received limited attention [12]. Though terrorism has been an ongoing life condition in Israel, to the best of our knowledge, the study of the longterm effects of terrorism on the Israeli general population since then has been relatively under-researched [13]. The majority of studies in Israel have focused on directly exposed individuals [14] and entailed clinical samples [15,16]. Such studies draw a clear distinction between the sick and the healthy and contain and confine the limits of the study of traumatic effects to an isolated group.

A landmark study by Bleich et al. [12] on the impact of ongoing trauma on the general Israeli population during the height of the second Intifada found relatively low prevalence of PTSD symptoms among the population at large. Moreover, the follow-up study at a two-year interval showed that while for some distress may be enduring, a large sub-group of individuals with elevated PTSD symptoms recovered (66.7% of PTSD cases and 39.3% of sub clinical PTSD) [13]. Another nationwide study conducted after a long wave of terrorist attacks in 2002 revealed that PTSD-like symptoms were reported by only 10.1% of the sample [13,17] concluded that Israelis were adjusting well, especially when considering the expected high prevalence of prior trauma exposure (e.g., wars, prior terrorist attacks, and the Holocaust), which is likely to increase the pathogenic effect of subsequent traumas. They further noted that the relatively low PTSD rates are particularly arresting when compared to the findings on the WTC attacks: “for all its devastation [The WTC Attack] occurred in a single day and far away from the homes of most Americans while trauma in Israel has been continual and in the vicinity of many Israelis’ homes,” they write (p.618).

A survey conducted by the Health Ministry of Israel reveals a similar pattern; “nearly one-tenth of the Israeli adult population (or 380,000 people) has witnessed a terror attack, but the vast majority still assesses their mental health as �very good’ or �excellent,’” writes Judith Siegel-Itzkovich in Jerusalem Post article published in March 3rd, 2005 [18] (p.5). When compared with data collected in Western European countries by the World Health Organization, Siegel- Itzkovich reports, it was found that the rate of PTSD was lower among Israelis than the average rate in Western Europe.

Cultural Differences

How do we understand the apparent adaptive nature of Israeli society in the face of trauma in comparison with their Americans counterparts? Does ongoing trauma (the Israeli case) indeed create habituation and better adaptation to living under traumatic conditions than a single, unexpected blow (the American case)? Or are there other factors at play? Research suggests that several post-trauma factors can function as buffers against PTSD. Among these is the ability to find meaning and make sense of the event [19,20] the existence of a biased positive belief about oneself [21,22]; and the availability of an adequate social network and support system [1,23]. Possibly, these factors account contribute to differences in the response to trauma between Israel and the US. Israeli society is governed by a communal ethos, characterized by collective values, while American society is structured around a liberal ethos characterized by the autonomy and individuality of its citizens. Illouz and Wilf [24]. Seeking others was a prominent and effective coping mechanism for Israelis during the Intifada [12], while social support strategies were positively associated with PTSD in the aftermath of 9/11 [8].

Cultural differences may also impact individuals’ attempts towards making sense of traumatic events. A qualitative study depicting narratives of 9/11 survivors [25] demonstrates that most individuals could not find any meaning or context for the attacks. As late as a year after the collapse of the towers, many New Yorkers still reported incomprehension: “there is no place to put this experience,” wrote the New York based author A.M. Holmes, “no folder in the mental hard drive that says catastrophe” (2002). In contrast, we speculate that it is seemingly much easier for Israelis from all shades of the political to place events within a national/ political context of the century long Israeli-Palestinian conflict and to draw meaning from them, even if it is a profoundly negative one.

As for the third buffer against PTSD - positive self-illusion - we note that even in the face of objective stress, Bleich et al., [12] study shows that the majority of individuals expressed optimism with respect to their future and the future of Israel and a sense of selfefficacy in the faceof a potential terrorist attack. This tendency for optimism and self-reliance, we suggest, is imprinted in the Zionist ethos itself. Indeed, we can trace the imperative to castaway sadness and tears back to early Zionist writings. “Why do you weep, son of man, and why do you hide/ your face in your hand?” asks God of the Witness to the Kishinev Pogrom of 1903 in Hayyim Nahman Bialik’s early Zionist poem “City of Killings” (Be’ir ha’hariga), “gnash your teeth and dissolve.”

Such ideological/ cultural specifics, we argue, impact felt and reported experience. As Marsella et al. [26] suggests, culture can amend the experience of post-traumatic distress and there are idioms of distress specific to particular cultures. While the capacity to experience fear, horror, and helplessness when exposed to a traumatic event is universal, it is the cultural factor, beyond individual differences, which may determinate the expression of fear and its likelihood to be evoked altogether [27].

The Accommodation Effect

In conjunction with cultural differences between the United States and Israel, we should consider the different nature of the traumatic events in each country: singular versus continual. As previously stated, it is widely agreed upon that traumatic effects and post-traumatic distress are cumulative [28]. Yet Bleich et al [12] show that in Israel, as traumatic events occur repeatedly and sequentially, levels of stress decrease and an accommodation effect sets in; people become habituated to living with trauma. Thus, it may be speculated that it is the continuous nature of trauma in Israel that operates as a mediator against acute emotional distress.

Literary works that were written during and about this period of Intifada in Israel (from the Jewish-Israeli perspective) indeed appear to depict habituation to living under conditions of prolonged trauma. One literary example is The Mission of the Human Resources Man [29] by A.B. Yehoshua, a prominent and popular Israeli novelist. The novel tells the story of the director of Human Resources at a large, industrial bakery, who is charged with making burial arrangements for an employee who killed in a suicide attack. Over many pages, the novel depicts a host of professional institutions that routinely, effectively and monotonously deal with terrorism and its effects: a well-oiled machine that habitually deals with the scores of dead bodies - from those in charge of identifying victims to those who deliver it for burial to those who calculate the State funded pensions distributed to dependents. All persons working for and in these institutions, and all those who come into contact with them, including the main protagonist, are depicted as acclimated to life with terrorism. None of those involved in “the mission”- to accompany the body of the foreign-born employee back to its final resting place in her native land – the clerk and his manager, the workers at the morgue, the airline cargo workers – display the least bit shock or distress at the terrorist act itself. They are habitual, efficient, desensitized and often comic professionals

It is this theme of habituation in the face of ongoing trauma that recurs in virtually all of the highly stylistically and thematically diverse works that treated the theme of life under the Intifada in Israel. In Orly Castel Bloom’s cartoonish-like postmodern novel Human Parts [30], the narrator begins by describing a host of catastrophes that befell Israelis at the beginning of the 21st century: terrorism, a particularly violent flu epidemic, and unprecedented cold weather, declaring that “people have gotten used to death.”

Is Accommodation an Adaptive Strategy for Coping with Trauma?

Is accommodation always positive? Do people, as the accommodation theory suggests, overcome the fear of a lifethreatening event in the same way they overcome a phobia, say from riding an elevator, where the more times they take a ride the less they are afraid? Perhaps this is not the right analogy, since terrorism trauma entails a more complex threat; it involves an objective stressor: a real life threatening event; it also has an arbitrary, random quality that shatters individuals’ deepest existential truths: that negative events are not distributed randomly, that bad things happen to bad people, and that justice will prevail [31]. Terrorism trauma is also man-made, and thus the victim has to be acclimated to the fact that someone, a person, did this to him or his loved one intentionally.

This raises the question whether Israelis indeed are more resilient to trauma or would a more complex portrayal of the psychological impact of trauma in Israel counter or at least temper the accommodation hypothesis? Israelis may be resilient if we measure resilience by a narrow definition of subjective distress and by means of self-reports questionnaires, as previously documented. Yet does this method of inquiry encompass the full range of emotional and societal distress in the general population?

We argue that if we assess psychological wellbeing pertaining to the inter-personal world rather than subjective distress, we capture the pathologies that are the side effects of resilience and the accommodation effect. Many of these pathologies also find expression in the literature of the Intifada. In Human Parts, for example, which as Castel-Bloom has testified was written specifically in order to document life under the conditions of ongoing terrorism; the author depicts a community unraveling at its seams, a set of isolated characters narrowly focused on their own survival. Underneath the surface of communal sharing and mutual support, alienation and lack of basic civility creep into even the most mundane tasks of everyday life. When, for example, the single mother Iris Ventura tries to get a jumper cable for her car from a “fellow citizen,” everyone refuses:

“She asked almost everyone driving past that hour on Jeremiah Street, but they all said they couldn’t help her. People were hurrying about their business. Whatever happened to “Kol Yisrael Haverim- All of Israel friends?” [….].

“Are you leaving?” someone who coveted her parking spot asked. “Only if you’ve got jumper cables…” she replied. “Do you have jumper cables?”…

Castel Bloom thus portrays alongside habituation the deterioration of social ties and social fabric under the pressure of ongoing trauma. And with its post-modern flatness blocking the reader from empathy and identification with any of the characters, the novel itself demonstrates this point most poignantly. Other Intifada-period novels, like Yehoshua’s aforementioned The Mission of the Human Resources Manager and Ronit Matalon’s Sara, Sara [32] are filled with characters whose inter personal lives are riddled with strife and conflict, even physical violence. Though these works do not present empirical data they may enhance our picture of life under conditions of continual trauma. As Paul Celan writes, “literature often shoots ahead of us.” “Writers,” states the literary scholar Shoshana Felman, “often feel compelled to testify through literary or artistic channels precisely when they know, or feel intuitively that in the court of history, […], evidence will fail or fall short” [33]. As we face a scarcity of studies and we question, for the ideological reasons, Israelis’ capacity to objectively self-report emotional distress - reporting on weakness may be perceived as “giving in to terrorism” or, as we write above, going against cultural norms of strength and self-reliance - literature may indeed provide the missing link. We liken novels to qualitative studies; they capture the subtleties of a subject’s cultural and personal context and give the reader a glimpse into a character’s daily life and interpersonal relations.

If we include a focus on the interpersonal realm in the definition of mental health, the differences between Americans and Israelis with respect to adjustment following trauma may even be reversed. As S. Dekel’s study [34,35] of 9/11 interviews demonstrate, though New Yorkers were less likely to seek others as a coping mechanism, they grew closer and sought more intimate social ties as a consequence of the attacks. Israeli Intifada-period novels portray a move in the opposite direction: towards disintegration and the breakdown of relationships.

We speculate that while the outcome of trauma in New York enhanced the social system, in Israel continuous trauma has had an aversive effect on communal social relationships. It seems like Israelis resemble the psychological type known as “the self enhancer.” Selfenhancers do not exhibit elevated posttraumatic symptoms following exposure to a traumatic event [22]; however, their strategies may be beneficial in the short term but maladaptive over the long term [36]. We believe that these simultaneous phenomena are not arbitrary and that the deterioration of social ties is the emotional price of the accommodation effect and of not expressing PTSD symptoms.

Psychodynamic Cultural Differences

Thus we argue that expressions of resilience and distress following 9/11 and the Intifada are culturally specific. More specifically, we argue that as a general rule emotional distress associated with trauma is internalized in the American case and externalized in the Israeli case. According to ego-psychology theory, the psyche can defend against overwhelming anxiety either by transforming it into symptoms experienced within the self or by projecting it outward, unto and towards an object. The American case, in which anxiety was generally transformed into PTSD and depression symptoms, follows the first model. One has only to glance at the collection 110 Stories: New York Writes After September 11 [37], to encounter 110 examples of flat-toned, depressive writing; in Israel, we speculate that anxiety is very short lived and is quickly transformed into feelings of anger and frustration towards others and a disintegration of the social fabric at large. As psychodynamic theory claims, anger is a means of masking anxiety; it is often safer to feel angry and perceive the other as harmful as to acknowledge anxiety and feel vulnerable. These defense mechanisms are associated with psychopathology [38] and indeed, as we have claimed, result in a wound to the social fabric. However, in the context of continuous threat to life, they may aid in preserving life. Anger, directed outwards, sets the person relatively free of intra-psychic symptoms and in a constant alert mode of fight, thus protecting him against emotional and physical death. Containing the distress within the self, as many Americans do, leaves the psyche depressed and anxious, unable to protect itself. Thus it seems that each culture chooses the adaptive mechanisms that are appropriate to both its “personality” and the nature of its trauma.

It has been suggested that people often regress in a safe environment; for example, patients become sicker in the safety of the hospital ward. Likewise, a single traumatic event (like the WTC attacks) followed by a period in which the stress is lifted, may allow people to express the full gravity of distress associated with trauma. Ongoing trauma (as in the Israeli case) is a traumatic state that has not ended. It is therefore safe in the “inter-trauma” and not in the posttrauma stage. In the inter-trauma stage symptoms may not develop, but this lack of expression should perhaps not be fully equated with resilience.

Conclusion

Just as psychodynamic theorists believe that the absence of overt signs of grieving only means that depression will eventually be manifested as a delayed reaction [39], we suspect that what researchers have called the “accommodation effect” may be a symptom of a delayed depressive anxiety reaction during the inter-trauma period. Thus, parallel to Elisabeth Kubler-Ross’s five stage grief theory [40], in which the mourner moves from denial to frustration to depression and finally acceptance, a society experiencing continual trauma may end up transitioning from frustration to depression as the threat diminishes. Yet we also claim that a respective society’s cultural inheritance and characteristics greatly affect the length and magnitude of these stages. Taking into consideration the limitations of this paper, further studies are needed in order to capture the full, subtle and dynamic experience of resilience, stress reaction and everything in-between in disparate populations exposed to ongoing or singular trauma. Such investigations should in our view include a study of both psychological and cultural dimensions, and their interdependence.

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