Unseen Scars of War: Psychological Consequences of the Hamas Attacks on the Israeli Civilian Population

Institute for Contemporary Affairs
Founded jointly with the Wechsler Family Foundation

Vol. 14, No. 25 July 21, 2014

Violence of war can lead to significant stress and impairment. Psychological consequences can be personal, social and occupational.

In some cases, these consequences move from manageable distress to more serious and longer-lasting post-traumatic effects (PTSD).

Missile attacks against Israeli residents of Sderot have resulted in major PTSD symptoms and significant disruption to lives and functioning to large percentages of the population.

While acute short-term distress has been reported, the relative physical protection offered by effective shelters and the “Iron Dome” may not prevent longer term consequences.

Protective measures have raised the confidence of Israelis and performed admirably, but if needed as a permanent and routine method of defense, it will not likely prevent attendant psychological impairment.

While attacks out of the 40km range have been more sporadic, Sderot serves as a model for what can be expected psychologically when attacks are sustained and adjustments required become part of one’s forced routine.

Violence and conflict associated with war is a classic cause of stress among civilians and military personnel. In some cases, the stress and strain is such that it is not easily resolved, leading to what clinicians have called “post-traumatic stress syndrome” or PTSD.¹

In the Israel-Gaza conflict, civilians are being exposed to the classic precipitants of stress-related issues during war, namely, unpredictable violence which threatens one’s physical well-being. While many eventually adapt and habituate², repeated direct exposure to threats of violence and actual attack has been shown to result in higher than normal rates of PTSD, with Sderot residents having multiple symptoms and consequences.³

Sderot is an Israeli town located one kilometer from the Gaza Strip. Residents typically have about 15 seconds warning by a siren to seek shelter from an incoming missile attack from Gaza. Since 2003, thousands of rockets have been launched from Gaza at Sderot and nearby towns.⁴ In the present conflict, much has been made of the “Iron Dome” anti-missile system. Its ability to intercept and neutralize missiles that would otherwise cause significant damage to people and property has resulted in a perceptible change in mood and behavior among the Israeli public.

Observers have noted that rather than showing signs of fear and panic, Israelis basically go about their daily lives, leading one writer to observe that “the better Iron Dome works, the less sympathy the rest of the world has for a nation that remains under rocket attack.”⁵ He goes on to write, “Bars, restaurants, and the Mediterranean beaches are still busy. Businesses are open. Although traffic is lighter than normal, the roads are hardly abandoned.”

International media outlets show shattered buildings on the Palestinian side⁶, and pictures of dead and wounded Palestinians⁷, but because of the success of Iron Dome, there is relatively little visible damage to the population on the Israeli side emanating from the ongoing Palestinian rocket attacks. To make the point, Allison Kaplan Sommer describes a scene from the “Daily Show” where “a Gaza reporter looked like an extra from the Oscar-winning Iraq war film “The Hurt Locker” and the one in Israel seemed as if he was about to grab a margarita and head for a Jimmy Buffet concert.”⁸ The conclusion reached is that the Hamas rockets are not really costly for Israel, making any Israeli military moves to suppress the Hamas attacks appear exaggerated.

This is a deceptively simplistic and short-sighted observation about the reality Israel faces that fails to account for the real psychological damage likely to take place as a result of repeated, long-term exposure to attacks. While the “Iron Dome” acts to reduce (not eliminate) the physical threat posed by missiles, the variables that can cause psychological distress are not necessarily mitigated by its success. Sderot serves as a model for the effects of long-term and constant, rather than short-term and intermittent, exposure to missiles. If other communities in the extendedrange of Gazan missiles continue to be exposed to attacks over a sustained period of time, there is sound basis to expect that many will learn to adapt and habituate, but also that, notwithstanding “Iron Dome,” many others will develop significant psychological impairment.

Sderot as a Model for Long-Term Exposure to Attack

There are indeed differences between Sderot and other Israeli towns with respect to missile attacks. For example, Sderot residents have much less time to seek shelter from an attack (15 versus up to 90 seconds). Sderot residents also have had very long periods of uninterrupted period of attacks, while other towns now protected by “Iron Dome” have not.

Post-traumatic reactions can result when one is exposed to a serious threat that creates feelings of intense fear, horror, and powerlessness. Post-traumatic reactions can include symptoms such as flashbacks, intense anxiety and fear that impair personal, social and occupational functioning.⁹ While “Iron Dome” communities until now have not had experiences that match those of Sderot, it is reasonable to assume that similar clinical phenomena may develop should “Iron Dome” become routine and require people to react multiple times per day to unpredictable attempts at causing them harm. Understanding the reactions and coping of Sderot residents would serve as an effective model for what could develop if missile attacks on extended communities also become routine.

We recently studied a group of Sderot residents who showed signs of stress-related symptoms.¹⁰ We wanted to understand what factors they saw as most critical to coping with their stress as well as to describe the functional effects of repeated attacks.

Functional Disturbances

Once PTSD-type symptoms are present, they directly impair one’s life. We heard cases of individuals who were so jittery that any sudden noise or move resulted in their being unable to move. One young woman, a former dancer, coped for years with missile attacks until she gradually developed severe tics, to the point of being unable to work, unable to establish intimacy with her husband and unable to go out in public as a result of poor self-image. When we interviewed her, she was gyrating so uncontrollably that she was unable to sit, and she stood for the entire interview. Another young man was a soldier assigned close to his home. Due to the similarity in sounds, he has developed a fear reaction to ambulance sirens and often loses control, freezes up or faints when he hears one. One woman who lived across from an area where several rockets have fallen spoke of the disruption to life caused by repeated trips to shelters during missile attacks. In a description that we heard from many other Sderot residents, she told of not being able to take a shower, sleep through the night or listen to music for fear of not hearing a siren and being unable to seek shelter. Children’s reactions were particularly acute and noted by almost all the parents interviewed. One parent spoke of her children suffering from bedwetting and being scared to use the toilet, for fear of missing a warning siren. Others reported having behavioral problems and difficulties in school and learning, attributing this to a state of constant nervousness, lack of sleep and strong reactions to sudden loud noises. For many, the lack of sleep, the heightened anxiety and the disturbed physiological reactions have caused significant occupational impairment. One man echoed what many others experienced saying that his jitteriness made him often unable to effectively communicate with his workers, and unable to meet work and production demands.

One couple summed up the situation by describing these reactions as “damage to one’s soul” and describing how “without a soul, a person can’t be a person.”

The Fragility of “Iron Dome”

While “Iron Dome” has brought a sense of protection to Israelis, it is not a perfect system. If a failure would result in a significant loss of life, the psychological pendulum would swing back towards creating anxiety. As behaviorist B.F. Skinner noted, even a single, isolated instance of “reinforcement” can have a significant effect on behavior.¹¹ Just as being attacked by a dog only once on a particular street corner can create lasting anxiety and fear of dogs, so could a single exposure to traumatic violence (such as a fatal missile attack) result in PTSD symptoms even if the event is experienced only through media exposure.¹² ut even in the absence of a traumatic event, the routine of the “Iron Dome” is not “normal” routine and the need for vigilance, the reality of anticipation and sustained, repeated and multiple interruptions that require stopping whatever one is doing to immediately go into “emergency” mode in order to avoid serious injury or death is a classic recipe for the development of stress-related symptoms.

Our Sderot sample also asked to rank the importance of various factors in their feelings of personal safety. Here, we were somewhat surprised as they overwhelmingly saw the “Iron Dome” of secondary importance to having a personal shelter. Their reasoning points to yet another possible psychological weakness of the system. While the “Iron Dome” does intercept incoming missiles, it often creates its own dangerous shrapnel as a result of the interception.

The Metamorphosis to Increased Stress

As Sderot has demonstrated, the danger of missile attacks is not only physical, but also psychological as a result of repeated exposure over the long term. Notwithstanding successful interceptions, such exposure is likely to cause stress symptoms of significance. Reliance on the “Iron Dome” is possible only as long as it is impenetrable and only when life can exist uninterrupted because of it.

However, the need to protect oneself from fallout from intercepted missiles and the continued need for constant vigilance in attending to sirens and taking immediate action to seek shelter will certainly disrupt life. If sustained over time, it will likely create another cohort (i.e., affected group of people) of “Sderot-like” symptoms in wider swatches of the Israeli population. Having the “Iron Dome” as a temporary mechanism for protection is fortunate, but if the system becomes part of a daily routine for Israelis, the love affair will likely be replaced by a sober realization that life is not going on as “normal” as some would want to believe.

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Notes

10 Mansdorf, I.J., Weinberg, M., & Weinberg, J., A study of stress symptoms in Sderot residents, Jerusalem Center for Public Affairs, in progress.

11 Schulz, D. and Schultz, S. Theories of Personality, Cengage Learning, 2012. page 317. (http://books.google.co.il/books?id=pRUKAAAAQBAJ&pg=PA317&lpg=PA317&dq=Skinner+found+that+a+single+reinforcement+was+powerful+enough+to+lead+the+pigeon&source=bl&ots=zty8AmHaWM&sig=TTXhHurBmJjehEXU4vi3-pVfnYw&hl=en&sa=X&ei=74TGU_LeA4z14QS-y4GYCw&ved=0CBwQ6AEwAA#v=onepage&q=Skinner%20found%20that%20a%20single%20reinforcement%20was%20powerful%20enough%20to%20lead%20the%20pigeon&f=false)