Wars, terror attacks and military operations have been a part of the Israeli population’s daily experience over the years. Recent examples include the Second Lebanon War (2006), the Cast Lead Operation (2008) and the Protective Edge Operation (2014). The Second Lebanon War took place in Israel during summer of 2006, after the kidnapping of three Israeli soldiers and an abrasive missile attack on the northern border of Israel by the Hizballah (the fundamentalist Islamic party that shared political control of Lebanon with Syria and Iran). The Cast Lead Operation (2008, also referred to as the Gaza War) was a military operation that was carried out in the Israeli Southern region, following seven years of missile bombardments from the Gaza strip aimed at the Israeli civilian population and in response to the kidnapping of the soldier Gilad Shalit by the Hamas and the Palestinian Authority. Protective Edge Operation (2014) took place after the kidnapping of three Israeli high school students at the Israeli Southern border, by the Hamas and the Palestinian Authority. By definition, the conditions associated with ongoing missile attacks, military operations, and wars entail certain effects on the targeted population (Ron, 2014; Shalev, Tuval-Mashiach, Frenkiel-Fishman, Hadar, & Eth, 2006). Despite the fact that ultimately, the majority of the civilian population suffered neither casualties nor loss of assets, the lives of the civilians in almost all of Israel’s northern and southern communities were in immediate danger and, in fact, the entire population in those areas experienced the conditions and the impact of war (Murthy & Lakshminarayana, 2006; Solomon, 1995).
The current manuscript reviewed the existing literature on the impact of wars, terror attacks, and military operations on civilians, professionals and para-professionals of various ages, gender, and ethnic groups in Israel. The purpose was to present an integrated view of the accumulated knowledge regarding these populations’ mental health and well-being. To this end, the author used a combination of qualitative and quantitative methodologies (Whittemore & Knafl, 2005; Besser & Priel, 2010).
A systematic review was undertaken using guidelines for identification of quantitative data (Higgins & Green, 2008). We set clear objective, formulated selection criteria and defined a search strategies for identifying papers. We then analysed the selected studies and synthesized the results using published guides for assessing randomized controlled trails and case control studies (Whittemore & Knafl, 2005). Although a systematic review is not imperative for an integrative review (Torraco, 2005), due to the sparsity of studies on the topic, a systematic review approach was conducted:
Numerous resources were perused, between the years 1980-2017, to identify studies that would serve as the basis for the integrative view offered herein, including:
a) references listed from nearly over an hundred items are cited in these reviews, included about 80 journal articles, six statistical manual, three doctoral dissertations studies and, 14 book;
b) references listed of about 30 other published articles and books’ chapters of the impact of wars, terror attacks, and military operations on civilians, professionals and para-professionals on the more general-world-populations regarding this topic in computer searches of the PsycINFO database (http://www.apa.org/psycinfo/);
c) nearly 240 abstracts identified in computer searches of the PsycINFO database (http://www.apa.org/psycinfo/) and Google scholar for the same topic in Hebrew.
The key words that were entered (in English and in Hebrew) into the various searches were posttraumatic stress disorder, secondary traumatization, and acute stress disorders (ASD)—all of which have been used to refer to a wide range of behaviours among different groups. The studies that were selected for use in the current review met the following criteria:
a) the review reported empirical data;
b) the review examined the impact of extreme negative life events such as terror attacks or wars on the well-being and mental health of various groups in Israel, including professionals and civilians, male and female, Jews and Arabs, elderly and young adults etc.;
c) the article reported on behavioral, psychological outcomes;
d) the article sample was restricted to populations of young adults (students), middle age and/or the elderly.
The final set of 101 qualitative and quantitative journal articles, books, doctoral dissertations, statistical manuals and surveys that met our purpose in the current review are included in the current integrative view.
A number of risk factors, such age, gender, ethnicity, were found to predict vulnerability to the development of mental disorders in the aftermath of wars or terror attacks, among Israelis between the ages of young adulthood and advanced age. These factors are often interactional and have a cumulative effect. Each is presented and discussed specifically in terms of their relation to PTSD, ASD and secondary traumatization.
3.1. The Impact of Military Operations, Wars and Terror Attacks
Terrorism, military operations and wars are often defined as the deliberate use of violence or the threat of the use of violence against professional armies, communities and innocent/unarmed people, with the aim of intimidating them into a course of action that they otherwise would not take (Primoratz, 1990). Stern (1999) defines national terrorism as an act or threat of violence against noncombatants, with the objective of exacting revenge, intimidating, or otherwise influencing an audience. The definition of national terrorism suggests some of the following consequences for the targeted population: loss of life, injuries and increased anxiety and fear. Studies conducted with direct and indirect victims of national terror attacks (i.e. survivors, witnesses, and close relatives of those who were killed) confirm that these individuals are at high risk of suffering from a distress reaction (Solomon, Mikulincer, Waysman, & Marlowe, 1991; Gidron, 2002; Shalev & Tuval-Mashiach, 2005; Ron & Shamai, 2011). The distress symptoms include generalized fear and anxiety, recurrent thoughts about the terror attack, avoidance behavior, physiological symptoms, depression, problems in daily functioning, and difficulties in relating to trusting others. In severe cases, such a distress reaction can result in varying severity levels of posttraumatic stress disorder (PTSD; Solomon & Mikulincer, 1991; Shamai & Ron, 2009; Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002).
Emotional changes that stem from an event such as war are determined to a large extent by the way in which the individual interprets reality and analyzes the likelihood of suffering personal or communal damage. The more threatening the event is perceived to be and the more the individual feels helpless facing the threat, the greater the chances of experiencing an enormous amount of stress and mental trauma. As to the trauma severity, it appears that the greater/more prolonged the physical and psychological exposure is, the more evident are the mental stress symptoms. It seems that most people are equipped with emotional resilience that allows them to recover quickly after such events, and the risk of developing severe mental health problems in response to such events is low (Bonanno, Rennicke, & Dekel, 2005; Dekel& Hobfoll, 2007).
Posttraumatic Stress Disorder, Death Anxiety, and Secondary Traumatization
The most common disorders following exposure to a war or a military operation are anxiety and sometimes also depression (World Health Organization, 2001). Yet, most people in the Western World do not experience a traumatic event such as war in the course of their lifetime, and only few develop PTSD. The disorder is characterized by a history of exposure to extreme mental stress situations that pose a threat to the individual’s life, physical health, or to the lives of others (American Psychiatric Association [APA], 2013). Various symptoms can develop as a result of the experience of a traumatic event, among them: nightmares related to the event; avoidance symptoms, which include reduced emotions and apathy; symptoms of hypersensitization of the autonomic nervous system, etc. (Ron, 2011; Chung & Hunt, 2014). When symptoms persist over a period of 1 to 3 months, the possibility of PTSD is considered. Symptoms that persist for more than 3 months and cause severe deficiencies in social and/or professional functioning suggest the condition of chronic PTSD.
Nevertheless, exposure to a traumatic event by itself is not a sufficient precondition for the subsequent development of PTSD. The professional literature has demonstrated that only a minority of individuals who were exposed to trauma developed PTSD or other trauma-related disorders (Ozer, Best, Lipsey, & Weiss, 2003; Johnson & Thompson, 2008; Johnson, Maxwell, & Galea, 2009). Aside from exposure to a traumatic event, other variables have been examined as PTSD risk factors. These factors are divided into three dimensions: pre-traumatic, peri-traumatic and, posttraumatic. The pre-traumatic variables are viewed as a predispositional vulnerability that existed before the traumatic exposure (e.g. history of psychiatric disorder, personality traits, biological and demographic variables etc.; Bomyea, Risbrough, & Lang, 2012). The peri-traumatic variables are those linked to the actual traumatic event and include the proximity to the event, peri-traumatic dissociation, the magnitude of the event, the occurrence of physical injury and its level, and the individual’s subjective appraisal of the event (Johnson, Maxwell, & Galea, 2009; Ozer et al., 2003; Weinberg et al., 2017). Posttraumatic variables, such as the individual’s reactions and coping abilities and the reactions encountered in one’s surroundings, influence the duration of the traumatic effect. A strong predictor of subsequent PTSD was found to be Acute Stress Disorder (ASD), i.e. the manifestation of symptoms three days to one month after the exposure (American Psychiatric Association, 2013).
It can be said of Israel’s northern and southern populations, and especially of those civilians who live near the borders, that their chances of being exposed to prolonged terror threats and to be injured in wars are far greater than those of the civilians who live in Israel’s central region. Researchers view these odds as prompting a unique type of trauma, characterized by civil hypervigilance, excessive concern, worry, and melancholy. In such circumstances, when an entire population (a city, a village, etc.) is exposed to the same stressor, the social preoccupation—albeit manifested in the positive form of community support and statements about mental strength—may in fact increase the distress rather than relieve it, as social networks can create an environmental effect that heightens fear (Hobfoll & London, 1986). However, research on the effect of prolonged terror threats, particularly in Israel, is relatively rare (Laufer & Solomon, 2009). After the second Palestinian “Intifada” (the uprising that took place between 2004 and 2006), Bayer-Topilsky, Itzhaky, Dekel & Mamor (2013) verified that all of their study’s respondents were exposed to terror attacks, either directly or indirectly: 35% were directly exposed, 66% were exposed through a family member, and 43% were exposed through friends. The prolonged terror threat evoked a basic change in individuals’ relationship with their environment, generating a continuous uncertainty in their habits of daily life.
A longitudinal study that was conducted during the Gaza War included 160 Israeli civilians living in Israel’s Southern region. This sample was divided into three groups, based on proximity to the Gaza strip: a) lived 4-25 miles from the border; b) lived 25-50 miles and c) lived more than 51 miles away from the border (Gil et al., 2015). The study’s findings confirmed the significance of ASD symptoms identified a week after traumatic exposure as the hallmark risk factor for a subsequent development of PTSD at one month. Previous studies showed that approximately 70% of trauma survivors who initially met criteria for ASD also met criteria for PTSD (Brewin, Andrews, & Valentine, 2000; Frans, Rimma, Aberg, & Fredrikson, 2005; Johnson, Maxwell, & Galea, 2009). Moreover, according to other studies (Van der Kolk, Van der Hart, & Marmar, 1996; Steuwe, Lanius, & Frewen, 2012), the findings of Gil et al. (2015) demonstrated the dual effect of dissociation on PTSD. Although immediately after the exposure, dissociative symptoms may reduce the risk for PTSD, in the long-run they have the opposite effect, increasing the risk for PTSD significantly. The initial dissociative reaction during and immediately after the traumatic exposure may ease coping with the traumatic nature of the event. Yet, prolonged dissociative symptoms may consolidate to become pathological. Fortunately, geographical proximity to Gaza did not show any association with PTSD. Conceivably, the war conditions and the reality that large areas of Israel were under constant missile attacks created a sense of uncertainty regardless of the variations in distance (Gil et al., 2015).
Death is an inseparable part of the circle of life and, as such, it is a natural universal phenomenon. The literature considers death anxiety a multidimensional term that associates death with an accumulation of unpleasant feelings that arise in the individual, such as fear, threat, and emotional discomfort (Neimeyer, 1997). Tomer (1992) offered a different definition, according to which death anxiety is a constant feeling, experienced on a daily basis, which is related to a general or a particular sense of loss, e.g., mental, physical, and social losses, loss of self or self-fulfillment, loss of control and independence, loss of health due to the body’s deterioration, and the effects of the loss of a loved one on one’s immediate surroundings.
The literature suggests that several demographic variables influence the individual’s death anxiety and other reactions to events of trauma and stress. Among those variables we can find age, gender, religiosity, as well as intra-personal variables such self-esteem and sense of mastery (Ron, 2011; Ron & Shamai, 2013; Ron, 2016; Chung, Preveza, Papandreou, & Prevezas, 2006).
Secondary Traumatization among Professionals and Para-Professionals
Over the last three decades, several researchers and clinicians have described the consequences of indirect exposure to a traumatic event, such as occurs, for example, when helping someone who has experienced trauma. McCann and Pearlman (1990)coined these consequences “vicarious traumatization,” whereas Figley (1988) used the term “secondary victimization” and later, the term “secondary traumatic stress disorder” (STSD: Figley, 1995a; Figley, 1995b). STSD and PTSD have identical symptoms (American Psychiatric Association, 2000). The difference lies in the type of exposure to the traumatic event; PTSD is a result of direct exposure, whereas the exposure resulting in STSD is an indirect effect of the empathic care provided to traumatized persons.
The very first empirical studies regarding the prevalence of STSD among helping professionals were conducting in the late nineties and the early 2000 (Arvay & Uhemann, 1996; Hyman, 2001; Myers & Wee, 2002). The focus of studies conducted to date on STSD has been on specific variables related to the development of STSD, such as the staff’s caseload, personal and professional experience, and exclusive exposure to traumatized clients (Shamai & Ron, 2009; Ghahramanlou & Brodbeck, 2000; Hyman, 2001; Lind, 2000). However, there is still a lack of knowledge regarding situations in which the trauma is not limited to one discrete event, but consists of a repeated experience lasting months or years.
In the literature, the impact of working with a traumatized population is often considered a function of two constructs, namely, burnout and secondary traumatization (Butollo, 1996; Kushnir & Melamed, 1992; Vicarcy, Searle, & Andrews, 2000). Researchers have suggested the concept of compassion fatigue as a construct of both STSD and burnout. Regardless of the similarities and differences between the two concepts, both of them are likely to have an impact on the level of stress experienced by helping professionals in the fields of general and mental health (Adams, Figley, & Boscarino, 2008; Perlman & Maclan, 1995).
Studies conducted among Israeli helping staff found that most staff members experienced a contradiction between their personal emotions and the demands of their profession at the moment when they were called upon to help after a terror attack or a military event. It must be said that Israel is a very small country geographically and in times of war or a national security crisis, it is likely that every member of the helping staff also has family members and relatives who might be personally at risk, whether as civilians who happen to be at the location of a terrorist attack or in the line of duty during mandatory military service. The transition from the routine professional work to the specific role assigned to social workers or nurses during a crisis such as an attack or a military event is usually very brief. Nevertheless, although the process is completed swiftly, it has a significant effect on the way in which helping professionals construct their experiences (Shamai & Ron, 2009; Ron & Shamai, 2013). Analysis of the data revealed that this process includes three steps: a) a sense of chaos; b) finding out whether their own family members are safe and well; c) physical and mental regrouping, in order to fulfill the specific role. Although there is a sense of chaos, depression, anxiety, and even some symptoms that characterize STSD, typically, these only lasted a few days, and in long-term, the helping staff members experienced personal and professional growth after successfully managing the encounter with and effectively assisting the victims and their families (Altman & Messler-Davies, 2002; Lev-Wiesel, Goldblatt, Eisikovitz, & Admi, 2008; Nuttman-Shwartz & Dekel, 2007). In contrast, other studies have found that working with traumatized clients often increases the level of personal stress, manifested as symptoms of PTSD and defined as STSD (Arvay, 2001).
The implicit contradiction between findings of personal and professional growth and findings of STSD symptoms can be explained by the context in which the studies were conducted. The extraordinary resilience and commitment to the State of Israel displayed by the Israeli staff is characteristic of how Israeli society as a whole copes with the large number of war and military events (Shalev & Tuval-Mashiach, 2005). These professionals feel attached and committed to Israeli society and their resilience can be attributed to social, as well as personal and professional variables. An additional explanation for the high levels of PTSD among helping professionals in Israel is related to the sociogeographic structure in Israel, which causes news of such events to travel fast and it affects everyone, either directly or indirectly. The immediacy and intensity of exposure creates an atmosphere of angst that engulfs the entire population, and almost no one remains detached. Fullerton, Ursano & Wang (2004) found that rescue workers exposed to a disaster reported significantly higher levels of ASD and PTSD than did a control group of workers who were not exposed to the event. Moreover, rescue workers with previous disaster exposure were 6.77 times more likely to develop PTSD.
Shamai & Ron’s study results (2009) indicated that the helping professionals’ levels of professional distress (burnout and intrusive memories) were associated with their levels of personal distress (level of stress). Several earlier studies conducted among nurses and other staff members in general hospitals, in Israel (Ben-Ezra, Palgi, & Essar, 2007; Essar, Ben-Ezra, Langer, & Palgi, 2008; Cohen, 2008), in Bosnia and Herzegovina, and in the US claimed that working with traumatized clients often increases the level of personal stress, which is manifested through symptoms of STSD, PTSD, and/or burnout (Chen, Chen, Tsai, & Lo, 2007; Hyman, 2001; Lind, 2000). Most of those studies concluded that the particular impact that long-term-caring for terror/war and/or trauma victims has on the individual is determined by numerous factors, including geographic location vis-à-vis the traumatic event, gender, age, cultural, mentality and participants’ profession and seniority at work (Essar et al., 2008). For example, one study found higher levels of stress among the nursing profession in comparison to social workers (both professions are considered feminine professions in the country of study) (Dekel, Hantman, Ginzburg, & Solomon, 2006). Yet another study found that compared with the hospital nurses, reported lower levels of psychological distress on all measures except anxiety, and an overall medium level of STSD (Luce, Firth-Cozens, Midgley, & Burges, 2002). Another study examined the impact of caring for traumatically injured patients on treating physicians and nursing staff. The study’s findings showed that the intensity of caring for these patients may contribute to the treatment team’s own stress and burnout. The same findings were reported by Chen et al., (2007), who sought to understand the experiences of nurses caring for victims of trauma. Nurses described fears about not being able to perform their job or function properly, feelings of frustration and guilt, especially if their patient died. Nurses also experienced restlessness, sleeplessness, nightmares, and intrusive memories following the care of trauma patients. Similar findings of anxiety, burnout, and STSD symptoms were reported among hospital nurses in other studies (Braithwaite, 2008; Laposa & Alden, 2003).
Regarding the para-professionals, there is no study about those workers in times of war. Ron’s study (2015) found high levels of PTSD and of death anxiety among Philippine migrant care-workers who came to Israel to find employment as personal and nursing aides to the elderly. The first explanation for those findings relates to the fact that most work immigrants from the Philippines had never experienced wars or military events. They did not know what to expect, what they should fear, or how they should behave. The issue of alarms that are heard routinely in wartime, the sounds of falling missiles, and the need to refrain from gathering in public places such as markets and public institutions all constituted new, strange, and terrifying experiences. When this type of event is experienced for the first time, it may certainly increase the individual’s level of anxiety, as is likely the case regarding the Philippine work immigrants. Moreover, the fact that their job demanded that they continue functioning in a routine fashion increased the sense of stress, both during the event and afterwards. After their initial experience of such events, they understood that military events are liable to occur again and again. They described posttraumatic symptoms, mostly disrupted sleep and intrusive memories. Also the high levels of death anxiety reported by the work immigrants were related to their experiences during the military events. This is not surprising, as it is expected that people who find themselves in areas where there are life-threatening events will begin to fear for their lives. It is also likely that the fear experienced by these people will intensify if they are responsible for the lives and welfare of their children, as was the case for several of the Philippine immigrant workers who participated in this study (Kelly, 2007).
Work immigrants from the Philippines undergo a process of adapting to a new culture that is entirely different from the one they come from. Often, the female Philippine work immigrants opt to leave their family members behind, even when it comes to young children who are still in need of their mother. In addition, the arrangement of living and sharing a household with the elderly person under one’s care is another type of stressor. All in all, it seems that the para-professionals continuously experience life events which for them are far from simple. In addition, it may be assumed sharing a routine with elderly people who are prone to experience higher levels of PTSD also affects the level of PTSD symptoms of the aides who care for them (Kelly, 2007).
Hare & Pratt (1988), in one of the first studies on the work stressors of nursing assistants in nursing homes compared the levels of burnout among nurses and certified nursing assistants and found higher burnout and depersonalization rates among the latter. The study also found that nursing assistants had more negative attitudes and less empathy towards the elderly patients than did the nurses (Astrom, Nillson, Norberg, Sandman, & Winblad, 1999). Other studies found that levels of stress (Estryn‑Behar et al., 1990), fatigue, and disrupted sleeping patterns were higher among nursing assistants than among other healthcare workers. This was most evident among those treating elderly individuals with cognitive deficiencies or impairments.
As mentioned before, the findings of Ron’s study (2015) involving Philippine migrant care-workers found low levels of burnout reported by the participants. These findings are not easily explained, for the following reasons. a) As far as we know, no previous research has studied the phenomenon of burnout among work immigrant aides caring for elderly individuals in times of war. b) In all of the above-mentioned studies regarding burnout, participants worked in nursing homes and their positions involved working in shifts. By contrast, in Ron’s 2015 study, the focus was on personal or nursing aides living in the elderly people’s private homes and providing round-the-clock care, thus filling a function similar to that of a family member. c) In an Israeli study about work stressors among nursing assistants and the connection to the workers’ well-being, findings indicated low levels of well-being among nursing-home workers (Ron, 2007). One of the conclusions was that most of the nursing assistants in Israel are well-educated and over-qualified women immigrants from the former Soviet Union, who had worked as physicians in their former homeland; their inability to find work suitable to their professional training and personal skills was a factor that increased their feelings of frustration. The Philippine aides, by contrast, were not well-educated and for them, taking this job in Israel was an opportunity to earn money to support their families.
3.2. Age and Gender Differences
Death anxiety is more clearly related to age groups: while youths report a high level of death anxiety and the elderly report a relatively low level of anxiety, there is no clear differentiation regarding the ages between the two extremes (Thorson & Powell, 2000). However, as an age group, the elderly experience a lower degree of death anxiety than do the in-between age groups (Fortner & Neimeyer, 1999; Azaiza, Ron, Gagini, & Shoham, 2010).
A major finding of Ron’s study (2014) was the significant difference between the levels of PTSD symptoms reported by elderly parents (171 participants of age 65 and up), their adult children (171 participants of ages 41 - 64), and their adult grandchildren (participants of ages 20 - 40), in terms of the levels of PTSD symptoms reported. The elderly reported much higher levels of PTSD symptoms than did their adult children. The hypothesis of the study, which predicted that the middle generation of adult children would report the highest levels of PTSD symptoms, was not confirmed. However, findings similar to those of that study have demonstrated that the negative effects of war, such as PTSD symptoms, are more common among the elderly population than among the young (Farhood, Dimassi, & Lehtinen, 2006). Farhood et al. (2006) explained this finding not in terms of age, but rather in the sheer amount of exposure to number of traumatic events: clearly, the elderly participants have been exposed to more traumatic events than their offspring. Presumably, the extent of exposure to traumatic events, in terms of both number and intensity, played an important role also in Ron’s (2014) study as well.
War is a negative event in the life the individual. It comprises many swift and dramatic changes that require adaptability on the part of the individual. According to Clipp and Elder (1996), the individual becomes more vulnerable with age and less capable of coping with negative life events. This observation helps substantiate the findings of Ron’s study (2014) and provide an additional explanation for the higher levels of PTSD symptoms found in the group of older participants.
Member of the elderly population in Israel, mainly—but not only—of the Jewish sector, many of whom immigrated to Israel from other countries, have experienced many/a lifetime of stressful events, including World Wars, the Holocaust, immigration, and in Israel numerous wars and terror attacks. It may be assumed, therefore, that the high levels of PTSD symptoms they reported are related to their initial state of vulnerability, which is greater than that of other younger participants (Van Zelst, de Beurs, Beekman, Van Dyck, & Deeg, 2006). Moreover, Ron’s study (2011) indicated that all participants filled out a questionnaire that examined the influence of previous traumatic events on the individual, including the levels of PTSD symptoms exhibited following those prior occasions. The data collected from the questionnaires of both the elderly parents and their adult children and grandchildren were reviewed, to determine whether prior traumatic experiences might have had a cumulative effect on the individual’s response to the current trauma. Findings indicated that the elderly participants’ higher levels of PTSD symptoms were in fact related to prior traumatic events and were not exclusively a reaction to the current wars. This finding thus strengthens the claim that the higher levels of PTSD symptoms reported by the elderly participants may be due, at least in part, to these participants’ vulnerability following numerous traumatic events experienced prior to this war. To further substantiate this claim, additional research should be conducted, to examine and attain a better understanding of the effects of prior traumatic experiences, and to determine whether such effects are significantly related to the PTSD symptoms exhibited following the latest traumatic event.
The lower levels of PTSD symptoms reported by the adult children of the elderly participants can be explained by referring to the meaningful role they assumed during the war vis-à-vis other family members (Ron, 2010a, 2010b, 2011). As part of the “sandwiched” generation, during the war they were probably called upon to provide extra support for both their own children and their elderly parents. It is possible that the aid and support that they extended at the time was significant in more sense than one, as this role gave meaning to their own actions and at the same time distracted them, in essence removing them from the sphere of the experience of anxiety and negative feelings, and thus helping them to cope emotionally during wartime. Accordingly, the levels of PTSD reported among members of this generation were lower than those reported by their parents. To strengthen this claim, the issue should be further examined in future studies.
To conclude, several possible explanations have been presented regarding the differences found in this study between the responses of elderly parents and those of their adult children regarding the emotional impact of the recent war. To further explore the suggested explanations, these groups should be studied, not only in the aftermath of military operations of war, but also in the periods of cessation of military altercations, when the population can return to the routine of daily life.
Typically, a higher percentage of men than women are exposed to potentially traumatic events, especially in times of war or military operations. Nevertheless several of the reviewed studies found that, regardless of age, compared to the men, women demonstrated a higher degree of psychological vulnerability, they tended to report stressful situations more frequently, their symptoms were more severe following a traumatic experience, and a greater percentage of women than men later developed PTSD (Folkman & Lazarus, 1980; Farhood et al., 2006; Bleich et al., 2006). Yet another study indicated that women reported significantly higher levels of PTS than did men and that the effects of age, noted especially among both Jewish and Arab women and among older Arab men, were an indication of the older adults’ vulnerability (Canetti-Nisim, Mesch, & Pedahzur, 2006; King, King, Foy, Keane, & Fairbank, 1999).
Relying on this literature, Ron (2011) hypothesized that the incidence of PTSD among the women would be higher than among the men. This hypothesis was confirmed, as the percent of women reporting PTSD symptoms was 19.3%, nearly double that of the men who reported PTSD symptoms.” (10%). Shamai and Kimhi (2007) conducted a study following Israel’s withdrawal from Lebanon. Their findings corroborated those of previous studies, indicating that the women in the sample experienced higher levels of stress than did the men (Anshensel & Pearlin, 1987; Kessler & McRae Jr., 1981).
One of the studies that explored gender differences in PTSD following a traumatic event did not reference traumatic situations of war or the ongoing threat of terror, situations that constitute a threat to one’s existence. Nevertheless, also the findings of those studies indicated that in severe situations, female participants reported higher levels of stress/a higher incidence of stress among female participants than among the male participants of their respective samples (Schraedley, Gotlib, & Hayward, 1999). One way to explain the gender differences is by claiming that the threat of war and terror pushes both genders into their traditional roles and limits the flexibility demonstrated by each of the genders. Regarding Israeli teenagers, war-like situations are likely to be associated with (recent or upcoming) mandatory military service. The socialization process in Israel prepares boys and girls to be soldiers long before they actually join the military, and although both genders are obligated to serve in the military, only men serve in combat roles (Gal, 1986; Ron, 2016). Male soldiers exposed to the conditions of war must control their fearful thoughts and emotions in order to be able to cope with the fighting (Dar & Kimhi, 2001). This socialization and conditioning may further explain the gender differences mentioned thus far.
However, it is less clear whether the finding of higher levels of death anxiety among women than among men in the majority of the studies reviewed herein is also related to the above-mentioned socialization and conditioning (Roshdieh, Templer, Cannon, & Canfield, 1998; Azaiza et al., 2010). It should be noted that Ron’s study (2014), like many of those which preceded it (Shamai & Kimhi, 2007; Ron & Shamai, 2013), was not able to clarify whether this finding might be related to women’s greater willingness to reveal their emotions or whether it reflects a greater vulnerability to traumatic events such as war.
3.3. Ethnicity Differences
Up until the First Gulf War (1991, known also as the “Desert Storm”), and later in the Second Lebanon War (2006) and the Cast Lead Operation (2008), the largest minority group in Israel, namely, the Arab population, had never been part of the population directly subjected to the attack of the countries engaged in confrontation with Israel. Since the establishment of the State of Israel, it had been implicitly assumed by both the Israeli government and this minority population that at times of war, the Arab minority would not be placed in either immediate or in potential danger, due to the existence of a Pan-Arab alliance. A study by Lavee & Ben-Ari (2003) noted that the Second Lebanon War was the first instance in which Jews and Arabs in Israel shared a frightening and distressing destiny (despite a similar situation during the Al-Aqsa Intifada). An additional study also noted the similarly high PTSD levels in the two population groups (Yahav & Cohen, 2007).
In the decade preceding the Second Lebanon War, members of the Arab minority in Israel used to openly demonstrate their support for the attackers, as well as their delight at seeing Israel attacked. This was especially the case Furthermore, the earlier behavior, seen during the First Gulf War, when large groups within the Arab minority in Israel were seen applauding the attack and singing songs of praise to Saddam Hussein (the former Iraqi dictator), encouraging him to kill as many Jews as possible. However, as the wars occurring in the area increasingly target the civilian population, Israeli-Palestinian Arabs have come to realize that in times of war, all of the citizens are subjected to the same dangers. Indeed, during the Second Lebanon War, more than 40% of the casualties (fatal and otherwise) among Israeli citizens were members of Israel’s Arab minority. Consequently, members of this minority no longer celebrate the attacks against Israel, but rather, they experience the same reactions of fear and anxiety described in the research literature reviewed herein. It is possible that to counter this sense of a shared destiny, members of the Arab minority in Israel increasingly reject the epithet that Jewish citizens of Israel use to refer to them, namely, the term Israeli Arabs, and prefer instead to be referred to as Palestinians.
The results of Ron’s studies (2014, 2016) suggest that rather than demonstrating the same degree of fear and anxiety as found among the Jewish population, the non-Jewish participants (Arab Muslims, Arab Christians, and Druze) reported higher levels of PTSD symptoms than did the Jewish participants. Also a significantly higher rate of possible PTSD diagnosis was found among the non-Jewish participants compared to the rates among the Jewish participants. These findings are in line with those of earlier studies conducted in Israel, which found that individuals of the Israeli-Palestinians Arab minority experienced psychological symptoms and symptoms of depression at higher levels than did their Jewish counterparts, and they exhibit a higher incidence of possible PTSD diagnosis following traumatic events, compared to the rates found among the Jewish participants (Hobfoll et al., 2008; Yahav & Cohen, 2007). As noted, Ron’s findings (2014, 2016) echo those of Yahav and Cohen (2007), which demonstrated higher levels of ASD among the Arab population after the Second Lebanon War. The explanations they offered for their findings are supported in Ron’s later studies (2014, 2016). Thus, for example, the researchers argued that although Arab citizens residing in Israel had been randomly wounded or killed in terror attacks in the past, the Second Lebanon War was the first time that they were not randomly but directly subjected to impending danger. It was also noted that since in the past the residents of Arab villages had always perceived themselves as onlookers from the sidelines, it had never occurred to them that they needed to prepare for the prospect of war. Consequently, during the attacks of the Second Lebanon War, there were no shelters or secure rooms available to them. This added to their feelings of helplessness and to the absence of any sense of mastery, feelings that when available are recognized as crucial protective resources that help people cope with traumatic events. The findings in the study of Johnson, Canetti, Palmieri, Galea, Varely, & Hobfoll (2009) showed that the Arab participants reported higher levels of PTS and depression symptoms, despite the fact that that they were not exposed to terror events at the same rate as were the Jewish participants. The authors suggested that the history of discrimination by the Israeli authority, the attitudes against them as an ethnic minority, and their empathy with the Palestinian struggle may have contributed to the impact of recent events on the Arab participants’ emotional distress.
It should be noted that historically, the Arab residents of Israel, who refer to themselves as Palestinians, either attempted to escape or were displaced from territories which became part of Israel after the 1948 War of Independence. A portion of them came back following the 1948 war and were granted Israeli citizenship, but the majority of them were—and still are—considered refugees by the UN. After the 1967 Six-Day War, the well-being of those Palestinians decreased further, because of the experience of living in an unstable environment or facing violence and acts of discrimination, persecution, and injustice, both from the Israeli occupation and from the Arab countries’ governments (Levav, et al., 2007). This history may have its impact on developing vulnerability found among the Arab population living in Israel, especially among the elderly people who experienced these events from early on. Some of the Arab participants in these studies may have been separated from their extended families, who reside in other Arab countries such Jorden, Syria, Egypt or Lebanon. We can assume that this vulnerability can contribute to the development of ASD, PTSD, and anxiety symptoms experienced in the wake of the wars and military operations mentioned above.
4. Discussion and Summary
The adverse psychological impact of being near a traumatic event and of working directly with people who have experienced trauma as a result of wars or military events has been discussed in this manuscript with reference to the literature on nurses, social workers and psychotherapists as well as the relevant literature about civilians’ PTSD-related experiences. The adverse psychological consequences of working with directly traumatized individuals have been described in various ways: PTSD, death anxiety, STSD etc. (Gil et al., 2015). In the context of the ongoing Palestinian-Israeli conflict, both professionals and civilians are exposed to prolonged periods of terror and to the ongoing threat of war (Somer & Bleach, 2005; Yaalon, 2005). Studies refer to this as a unique type of trauma, which causes the Israeli population excessive concern and worry, death anxiety, PTSD and STSD. It should be noted, that in such circumstances, when the entire population is exposed to the same stressors, external resources such a social support may deepen the distress, rather than relieve it (Hobfoll & London, 1986). However, research on the effect of a prolonged terrorist threat and wars, particularly in Israel, is relatively rare. For example, there is no body of research that compares stress before and “after the war” and this fact—in-and of-itself—has an affected the scope of our collected knowledge. Given the information collected here, the modification of the PTSD diagnostic criteria calls for a reexamination and revalidation of risk factors for PTSD. Currently, being near a traumatic event, being a middle age civilian Arab female, experiencing a war or a military event for the first time in one’s life are all risk factors for developing PTSD.
The findings of the manuscripts described herein led us to several conclusions.
a) The manifestation of ASD symptoms immediately after a traumatic exposure is the most prominent risk factor for developing PTSD two or more months afterwards (Gil et al., 2015; Johnson, Maxwell, & Galea, 2009). Research has shown that approximately 70% of trauma survivors who initially met the criteria for ASD also met criteria for PTSD (Frans et al., 2005; Kessler et al., 2005).
b) Although in the immediate aftermath of the exposure dissociative symptoms may reduce the risk for PTSD, in the long-run they have the opposite effect, increasing the risk for PTSD significantly.
c) The ongoing threat of terrorism, wars and military events is a unique type of trauma (Somer & Bleaich, 2005; Yaalon, 2005; Wilson, 1995). This raises the question regarding the length of time that constitutes a prolonged threat. Further research on the topic is warranted (Laufer & Solomon, 2009).
Several practical implications emerge from this review. First, professional and paraprofessionals competence should include understanding culture as dynamic and ever-changing. There is a need for increased awareness of ways in which cultural norm, beliefs and patterns of coping might differ among ethnic subgroups or individuals. Regarding the Israeli case, in which the Arab and the Jewish populations live side by side, holding different perceptions and sometimes can be confused about their role in times of war-this which is crucial and even mandatory. For example, when the professionals’ patients, war’s trauma injures, are lying in the hospital room.
There is also a need to understand and to learn more about the gender differences in coping with ASD, PTSD and Secondary traumatization both among civilians and professionals as well as the differences between age groups. For example men may express less or lower levels of emotion such as anxiety, depression or despair than women will (probably because of the socialization processes).
Several limitations and precautions in respect to the review should be noted. First, the review consists of relatively few studies, using diverse methodology. Moreover, a considerable number of the studies in this review reported on differences between groups, but they lack evidence showing that the observed differences are due to ethnicity, situational, political and demographic factors. Further research should focus on identifying the various sources of differences between groups with the aim of gaining a deeper understanding of whether and which of those factors best explain the results.
More expansive research on the cultural aspects of the impacts of wars, military events and terror attacks in the different groups in Israel and in other ethnic groups worldwide, is essential to expand our knowledge of psychological aspects of coping. Ashing-Giwa and Kagawa-Singer (2006) coined the term “culturally competent research”, a pursuit that may require unique research methods and specific research tools.