Factors That Facilitate and Hinder Rehabilitation and Posttraumatic Growth Among Operation Protective Edge Veterans

Combat situations constitute one of the most extreme instances of stress events, thus exposing the soldiers involved to a range of occurrences including physical and mental injuries that increase the risk for the development of post-traumatic stress disorder (PTSD). Whether strictly physical or emotional or a combination of both, the injury requires a process of rehabilitation to enable the individual to return to an active, fulfilling, and productive life and participation in society. As multiple factors may support or hinder rehabilitation, the process is of utmost importance.

Following the events and aftermath of October 7, large numbers of soldiers and reservists are turning to the Ministry of Defense’s (MOD) rehabilitation department —the main government body overseeing recognition and treatment of soldiers injured in the line of duty and in military service context. More than ever, there is an urgent need to examine, from a broad perspective, the rehabilitation process and the effectiveness and contribution of various components included in key rehabilitation models.

The present research aimed to examine the variance and factors supporting and hindering rehabilitation and post-traumatic growth (PTG) among soldiers who participated in operation “Protective Edge” (2014) and who applied to the MOD for formal recognition of status. The reason for choosing this particular population was based on the fact that these are injured individuals receiving treatment and services within the MOD rehabilitation department, and this study sought to examine predictors of rehabilitation among those being treated in this particular framework. Furthermore, this population was the youngest group to come under the rehabilitation department’s care in the period leading up to the research. Considering that rehabilitation and growth processes may extend 5-10 years, a relatively late time-point was chosen for examining the study variables in order to assess the participants’ condition at a fairly advanced stage in their coping process.

Two models serve this study to measure rehabilitation. The first is the social-functional model – the International Classification of Functioning, Disability and Health, or ICF (WHO, 2002), which is based on a bio-psychosocial approach and offers a system for recording and coding of the individual’s capabilities and limitations, evaluating functioning levels, and distinguishing between supporting and hindering factors. The ICF model identifies independent variables that are predictors of rehabilitation, grouped into five categories: physical health, functioning, participation in the recovery process, environmental variables, and personal variables. These five groups can predict the result variable, defined in this study as Rehabilitation, and which the ICF model terms as Activities and which represents the individual’s performance of tasks within their rehabilitation process. The present study measures this variable through the following three variables: integration in employment, level of education, and being in an intimate relationship.

The second model employed in this study is the Post-Traumatic Growth model, or PTG (Tedeschi & Calhoun, 1995), which is examined in light of the current definition of rehabilitation that views post-traumatic growth as an integral component in the process of adapting to disability. These two models, and the combination between them, allow this study to expand the classic measures of rehabilitation and provide a wider and more coherent picture that can better explain functioning, disability, and health.

Method: The invitation to participate in this study was carried out through a personal telephone call to 556 veterans injured in combat during operation “Protective Edge” who applied to the MOD’s rehabilitation department for recognition as disabled IDF veterans. Of these, 376 (67.7%) accepted the call and received information about the research. Of these, 297 expressed willingness to participate in the study and received a link to an online questionnaire via email or their mobile phone, as per their stated preference during the call. Of the 202 (68%) that filled out the questionnaire, 182 (90%) completed it fully, and were therefore the final research sample.

Data collection and research tools: The independent variables were collected via a computerized demographic questionnaire filled out by the research participants, and included data assigned by and provided to soldiers prior to induction: medical profile, and initial psychometric and demographic score. Additionally, the questionnaire collected data on their current status following the injury, based on the five groups of variables outlined by the ICF model. The health variables included the nature and severity of the disability; functioning variables included use of instrumental resources, such as compensations, a mentor or escort for daily functioning following the injury. Participation variables examined the individual’s involvement in self-care and treatment, such as through psychotherapy. Environmental variables included place of residence and social support, and personal variables included the type of army service, military rank, and the number of years (graduating) of education. The demographic questionnaire also collected information on the nature of the injury, disability percentage, and place of residence; this data was cross-referenced with the information received from the MOD.

Finally, the participants were asked to complete self-report questionnaires with questions about their health, PTSD Checklist(PCL-5; DSM-5), exposure to combat, social support, happiness in relationships, and PTG.

Data analysis: included descriptive statistics regarding the study variables. The correlation between the study variables examined by validated questionnaires – PTSD symptoms, social support, PTG, happiness in an intimate relationship, and exposure to combat – were tested by Spearman’s rank correlation coefficient. Logistical regression was carried out to examine the unique contribution of the variables of psychotherapy, social support, and exposure to combat to the link between the PTSD symptoms (measured by PCL-5) and the rehabilitation variables (employment, education, and relationship), and the association between those rehabilitation variables and PTG was examined by linear regression as well as moderation and mediation testing using Process Macro software. Finally, for constructing a model and examining the overall unique contributions of the explanatory (independent) variance variables (health, psychotherapy, severity of PTSD symptoms, exposure to combat, and social support) to explaining the rehabilitation variables (intimate relationship, education, and PTG), pathway analysis was conducted.

Main results: On the whole, the study indicates that of the independent variance variables examined in this study, objective and subjective health, PTSD symptoms, psychotherapy, exposure to combat, and social support were found to explain three of the four rehabilitation variables -- employment integration, intimate relationship, and PTG (the fourth being level of education).  Some of the independent variables are associated with the rehabilitation variables directly, and others through the mediating variable of social support.

Post-traumatic growth: PTG levels were found to be high (Mean [SD]70.828 [18.085]) among 75% of the study participants and was explained by all groups of the independent variables. This leads to the conclusion that post-traumatic growth is present in all spheres of life of the injured individual undergoing rehabilitation and may be enhanced both personally as well as through various family, relationship, and community systems.

Integration in employment was found among 74% of the study participants and was also found to significantly correlate to objective and subjective health measures. This leads us to understand that an individual’s self-perception of their physical and mental health is highly meaningful in the process of rehabilitation.

Intimate relationships: fifty-seven percent (57%) of the study participants reported being in an intimate relationship. The variables that explained this are the type and nature of the injury, and social support. Higher numbers of participants with physical injuries only were found to be in intimate relationships than participants with an injury including a mental component. Additionally, social support was found to be significantly positively correlated with this variable, meaning that social support was higher among the participants who were in a relationship compared to those who were not.

Research limitations: Several limitations to this study must be acknowledged. First and foremost amongst these concerns the research design, which studied the participants at a single time point 8-9 years after the military operation, thereby reflecting only one point on a time axis, with no baseline and therefore no ability to assess change over time.

The second limitation regards the recruitment of participants for the study. Recruiting the participants was challenging both due to the sensitivity of the subject, as well as practical difficulties in contacting the relevant population. During the period of the data collection, several military events took place (including “Guardian of the Walls” in 2021, “Breaking Dawn in 2022, and “Shield and Arrow” in 2023), which may have adversely impacted willingness to participate in the study. As a result, the study sample was relatively small and not necessarily representative of the intended target population. Furthermore, a certain bias may derive from the fact that the study included only participants who agreed to participate in the research. In addition, the study is based on a self-report questionnaire and therefore relies on trust in the participants’ responses as well as their degree of subjectivity. Aside of objective data collected from the MOD’s rehabilitation department, medical diagnoses, and disability percentages, the remaining variables were collected by means of a self-report questionnaire, and on top of that, at a distance of nearly a decade since operation “Protective Edge”. 

The contribution of the research: This study makes an important theoretical contribution by combining, for the first time to our knowledge, between two models that examine rehabilitation and post-traumatic growth, thus expanding the holistic understanding of the processes of rehabilitation of soldiers post-combat in general, and Israeli soldiers in particular. Additionally, in the present research, the perception of rehabilitation  has been expanded to include Activities – the result variable in the ICF model, which is defined there as one’s ability to perform tasks or actions, and which serves as a significant measure of the degree of one’s independence in coping with the day-to-day demands. The components of Activities as per the ICF model are measured through the extent to which they are implemented in the main spheres of life, including: learning and applying knowledge; general tasks and requirements; communication; mobility; self-care; interpersonal communications and relations; studies and employment; and, engaging in social and community life. In the present study, Activities refers to integration in employment, level of education, and being in an intimate relationship, and expands to post-traumatic growth, which refers to the construction of cognitive schemes that reflect insights from coping with the traumatic event.

This research also offers several practical contributions. The first of these is creating an integrative evidence-based model that is unique to the population of soldiers in the care of the rehabilitation division of the MOD in Israel. The second is the understanding of the critical role of one’s subjective perception of their health, beyond the objective measures reflected in the percentage of disability and diagnoses determined by the ministry’s medical board. And finally, the model has the potential to serve as an applicable tool for evaluating and constructing a multi-phase treatment plan that takes into account both the individual’s subjective perception of their health as well as the cumulative knowledge regarding the effectiveness of the various rehabilitation components, such as psychotherapy and post-traumatic growth, beyond the post-traumatic symptoms.

Recommendations for continued research and policy: This study includes several recommendations for future avenues of research as well as for policy. To begin with, future research should increase the number of research participants. In terms of policy, the current research’s findings should be extended also to soldiers and veterans injured in the current “Iron Swords” war that followed the events of October 7, as well as previous military operations and past wars. In addition, there is need to consider expanding the review of the services currently provided by the MOD as part of the rehabilitation plan, such as, for example, psychotherapy for children and family members, service dogs, mentoring for children, support and therapy groups, participation in resilience programs, and more. Additionally, there is need to expand the review to include pre-injury variables that may predict future post-injury rehabilitation, such as psychometric data and military placement and assignment information and various variables pertaining to their course of military service, which should be done in collaboration with the ministry, and which may help identify populations that will require additional resources throughout their rehabilitation. We also recommend expanding the examination of social support, which this study has found to be a moderating variable that impacts the rehabilitation results. 

 To conclude, the rehabilitation process plays a critical role in the injured soldiers’ adaptation to disability and return to a fulfilling and productive life routine. Evidence-based intervention is critical both at this point in time in particular, as well as going forward. The present study and its results can provide a working model for the staff and management of the MOD’s rehabilitation department seeking to examine the approach and the results of the rehabilitation as well as the results they should have in mind while setting out the rehabilitation plan. The research findings point to several factors that support rehabilitation, and which should be taken into account when constructing intervention plans, such as enhancing self-perception of health, strengthening social, familial and relationship support systems, and finally, promoting post-traumatic growth.