Adjustment profiles of Yom Kippur war veterans seeking delayed help from IDF

Over the course of its entire existence, war and terror have been an integral part of life in the State of Israel. One of the most difficult wars, and perhaps the most traumatic one, was the 1973 Yom Kippur War. Notwithstanding Israel's impressive military achievements, a sense of failure prevailed in the wake of that war, and it was ultimately defined as a military and political blunder.

            Soldiers who serve in wars can experience immediate stress reactions, i.e., combat stress reactions (CSR). They can also develop long-term symptoms such as post-traumatic stress disorder (PTSD). These reactions have a great impact on   lifestyle and quality of life, and harm victims' personal, familial and social functioning as well as their physical health. However, out of the large number of people who develop PTSD, only a few request psychological help.  Most do not seek such assistance, owing to the lack of awareness of the relationship between their psychological distress and the events they experienced, as well as to other factors such as shame or guilt.

            For men in particular, a delay in seeking psychological help is complex, and findings have revealed that this delay can also be attributed to masculine stereotypes (Galdas, Cheater, & Marshall, 2005). Notably, in Israeli culture in general and Israeli military culture in particular, men are expected to be tough, to suppress their feelings, and to avoid feminine traits such as compassion, sensitivity, and tenderness (Moller-Leimkuhler, 2002). In this context, very little research has been done on delayed help-seeking among men in Israel in general and among men in the Israeli army in particular.

One discovery I have made during my long-term work in the Combat Stress Reactions (CSR) Unit of the Israel Defense Forces Medical Corps is that in recent years, many Yom Kippur War veterans have suddenly requested psychological help.  Consequently, the present study aimed to gain deeper insights into this group, based on a retrospective examination that took place more than 30 years after the event. Toward this end, two models were used. The first model, the ecological model, relates to the variables of the traumatic event, the individual, and the individual's social environment, in an attempt to shed light on delayed help-seeking (Gitterman & Germain, 1976). The study was based on a specific adaptation of the ecological model to the area of help-seeking, which relates to the individual's tendency to seek help (Tijhuis et al., 1990). The second model, Erikson's (1963) developmental model, was used in an attempt to understand the research findings.

The first aim of the research was to examine the long-term adjustment patterns of Yom Kippur War veterans who only sought help after a period of more than 30 years. Adjustment was examined using three dimensions: post-traumatic stress, functioning, and state of health. The second aim of the research was to classify the participants according to categories of stress patterns, based on a common profile of symptoms. The third aim was to examine the contribution of the following variables to explaining the participants' adjustment: the characteristics of the traumatic event (exposure to injury/death of IDF soldiers, exposure to injury/death of enemy soldiers, exposure to helplessness in combat, exposure to injury/death of acquaintances); the characteristics of the person (demographic characteristics: age, country of birth, education, employment,  and guilt and stressful events: positive and negative life events that took place before and after the Yom Kippur War); and characteristics of the environment (social support: marital status, and  formal support: e.g., other requests for psychological or medical help over the years).

The sample of participants consisted of 195 Yom Kippur War veterans who had experienced a process of assessment and evaluation through questionnaires (based on the DSM-IV) at the time they came to the CSR unit, as well as via intake interviews conducted between 2006 and 2012. Data were collected from the files of the participants. Besides using structured questionnaires to assess post-trauma, functioning, and guilt, we conducted content analysis of intake interviews (Chamaz, 1995; Pidgeon & Henwood, 1996), in which the participants described the symptoms they experienced and how they functioned over the years: from the time of the Yom Kippur War until they arrived at the CSR Unit. The following main research variables were derived on the basis of content analysis: characteristics of distress as reflected in symptoms reported by the participants, health problems, the traumatic event (i.e., exposure to combat), stressful life events (positive and negative), guilt, marital status, and help-seeking.

Several methods of analysis were used in the study. The Hierarchical Linear Model (HLM) was used to examine the development of psychological distress. To classify participants according to patterns of distress by the level of their symptoms (symptom profile), we used Latent Class Analysis (LCA). The analysis was based on the last point in time when the participants sought help. To attain the third research goal, i.e., to estimate the contribution of the independent variables to the level of each symptom, we used several methods of analysis which were adapted to the distribution of each symptom: negative binomial, Poisson regression, zero inflated Poisson regression, zero inflated negative binomial and logistical regression. We used hierarchical regression for the variables that were examined on the basis of questionnaires (post-traumatic symptoms, functioning, and guilt).

The findings indicated that 90.8% of the participants experienced post-traumatic stress disorder when they arrived at the CSR Unit. The direction of the development of psychological distress over the years, as reflected in the symptoms reported by the participants, reveals a pattern of sub-clinical post-traumatic symptoms that escalated to the point of full PTSD by the time they arrived at the CSR Unit. Latent Class Analysis revealed that the participants belonged to three classes: those who mainly experienced anxiety and depression; those who experienced few symptoms; and those characterized by a high level of violence.

The research hypotheses were partially confirmed. Of the components that characterized the traumatic event, the findings indicated that participants who had reported more "exposure to death of IDF soldiers" also indicated that they had more symptoms of avoidance, violence, and physical symptoms. The participants who had reported more "exposure to helplessness" during the war indicated that they had more problems functioning and symptoms of fear. In addition, the findings revealed that those who had been injured at the time of the event experienced fewer symptoms of avoidance. In addition, a significant positive relationship was found between stressful life events (over the years) and health problems. During the year preceding the request for help, a significant positive relationship was found between stressful life events and functioning, post-traumatic symptoms, and symptoms of fear. No significant relationship was found between positive life events and adjustment.  Enlisted soldiers were more likely to develop invasive symptoms and to show lower functioning than officers, whereas officers were more likely to report depressive symptoms than enlisted soldiers. Furthermore, a significant positive relationship was found between guilt (upon arrival at the CSR Unit) and post-traumatic symptoms. Employed and married participants experienced fewer post-traumatic symptoms, higher levels of functioning, and fewer health problems than their unemployed and unmarried counterparts.

The above findings highlight the need for professional staff, within and outside of the army, to reach out to people who fought in wars or experienced other traumatic events. This is an important conclusion, in light of the high rates of participants in the study (90.8%) who were found to have post-traumatic symptoms. In addition, the findings support the argument that delayed onset of PTSD without a background history of symptoms is rare, and indicate that most of the people who seek help report that the background symptoms intensified over the years until they developed into full PTSD.

One limitation of the study derives from the retrospective design, which relied on the participants' memory many years after the event. Other limitations relate to the number of participants in relation to the number of soldiers who fought in the war, as well as to the fact that the participants were those who had actively sought treatment, and there was no comparison group.

Known and validated questionnaires were used for formal diagnosis; in addition, we conducted in-depth intake interviews, in which participants were given space to tell their personal stories and researchers were able to examine areas that a closed questionnaire would not have revealed.

The current study is part of a series of retrospective studies relating to the impact of war on the soldiers who fought in it. It would be worthwhile to further examine the relationship between the components of post-traumatic stress symptoms and risk factors or protective factors for PTSD using the integrated instruments employed in this study. Doing so could both shed light on the disorder and alleviate symptoms; it might even prevent the development of PTSD years after the event.