HOW DO YOU CONVINCE A SOLDIER TO RETURN TO THE BATTLEFIELD? AN INTERVIEW WITH THE IDF'S OUTGOING MENTAL HEALTH CHIEF

How Do You Convince a Soldier to Return to the Battlefield? An Interview With the IDF's Outgoing Mental Health Chief

The head of the IDF's mental health department and its array of therapeutic units are coping with the biggest psychological crisis the army has faced since 1973. But, Dr. Lucian Tatsa-Laur says, if soldiers are brave enough to fight, 'they won't fall apart after going home'

March 23rd, 06AM March 23rd, 06AM

The first three phone calls that Col. Lucian Tatsa-Laur, outgoing head of the Israel Defense Forces Mental Health Department, made on the morning of October 7 gave him an initial, chilling idea of the scale of the catastrophe that had begun to unfold in the south.

"The first call was to the mental health officer of Southern Command, Maj. Lior Turhanski," Dr. Tatsa-Laur recalls. "She replied in a whisper that she was in a safe room with her children and that her husband was outside, doing battle in one of the kibbutzim near the Gaza Strip. I called her deputy, the mental health officer of the Gaza Division, Maj. Keren Popovich, who told me, 'I'm trying to reach someone at the division [headquarters], but it's been captured.' I told her, 'No way.' After all, Re'im was the safest base."

At first it all looked unreal.

Tatsa-Laur: "Yes, confronted with the atrocities of Hamas, it took us time, as part of a gradual process, to grasp that it had really happened. A hallucinatory reality was evolving – those first weeks seemed something like a movie. And that also describes how we experience trauma in general. People who develop post-traumatic stress disorder feel as if they are in an alternate reality created by the trauma, and that is one of the challenges of treatment."

The psychiatrist's third phone call that morning was to Lt. Col. (res.) Yoram Ben-Yehuda, commander of the Home Front Rehabilitation Center, which is staffed by reservist mental health experts who treat soldiers suffering from PTSD and other complex reactions to battle. This is an ad hoc framework consisting of several branches around the country, which is in operation during wartime and was last activated during the Yom Kippur War. According to Tatsa-Laur, Ben-Yehuda replied, "I await your orders, but my son is at the Paga outpost [near Kibbutz Be'eri, close to the Gaza Strip]. He was shot in the stomach, but no one can get to him." The son, Itamar Ben-Yehuda, did not survive.

"Yoram sat shiva for his son – and then returned to take command of the rehabilitation center," Tsata-Laur relates. "So, from the first minutes of the war, it was a huge event with immense psychological ramifications that touched us personally."

The biggest mental health event for the army since the 1973 war occurred on your watch.

"Yes, and on the day it happened it didn't seem like some sort of a [professional] opportunity. You're part of an organization and feel the great sense of failure."

Restoring confidence

Today, just a few weeks after he retired from the IDF, Tatsa-Laur, who is 49 and lives in Jaffa with his wife and their three children, is able to offer some perspective on what has happened to Israel since the war broke out.

"This is an event of historic dimensions. Israeli society will not look as it did beforehand, for good or bad," he says. "We have seen amazing displays of camaraderie, commitment and solidarity, along with evidence of a massacre and our failure as an invincible army."

Until the war, in his capacity as the IDF's "minister of mental health," Tatsa-Laur dealt mainly with the routine challenges of ensuring the psychological well-being of the troops, which were plentiful even then.

"During the past few years, there's been a gradual increase in the demand for mental health services in the military," he says. "This is actually a general trend around the world, in part due to the COVID-19 epidemic. There is always a shortage of therapists and budgets. In the period before the war, the IDF took a leap forward regarding the quality and experience of its mental health services."

He adds: "When there is a conscript army in a democratic country, people think that it is the law that obligates them to be drafted, but in the end Israelis serve in the IDF because they believe that the army knows what it's doing, that there is a justified reason for its existence and activities. And no less important, that there are those who will be there for them and look after them if they're hurt. The sole moral right I have for endangering a soldier's health is earned when he has to face the presence of an enemy in threatening situations. My mission is to ensure that I do not endanger a soldier's life or mental health for other reasons."

And then an event occurs on a scale that no one could have imagined. What do you do?

"You start with a feeling of failure and that there is no one to rely on, and you understand that our primary mission is to restore and rehabilitate the confidence that people have in us. To begin with, we mobilized a large number of mental health officers. At the height of the war, there were 800 of them active in the reserves."

Together with the huge call-up of mental health personnel as part of their reserve duty, the IDF made two important decisions at the very start. First, that those personnel would not focus on treating soldiers suffering from combat-related stress, but on training the commanding officers of those soldiers to help them grapple with their problems. The second was not to allow volunteer therapists to treat soldiers if they hadn't undergone dedicated training.

"There was some indecision about this subject, because there are two psychiatric 'fantasies.' One is that everyone who is exposed to harsh sights or incidents will develop PTSD that will stay with them for life. [Symptoms of the disorder include nightmares and flashbacks, aversion to elements that trigger memories of the trauma, moodiness, angry outbursts, problems with concentration, etc.] The second is that if a mental health staffer or a psychiatrist talks to you, it will disappear. Both fantasies are incorrect, but there must be some intervention and the decision was to instruct the commanders and not to treat combat-related stress as an illness [that cannot be treated successfully] per se – and that is significant."

Why didn't you let volunteers help?

"Because even if someone is a great expert on PTSD in civilian life, and treats people with chronic trauma, the clinical picture they would be encountering now is completely different from that of a totally healthy population that reacts to a catastrophic event. If you look a soldier who went through a harrowing event with the same level of shock and empathy that are reserved for chronic cases, you will imbue him with the perception that he is sick."

What does the research literature say about proper intervention in cases of PTSD [during wartime]?

It's very difficult to return to battle after a home furlough, and there are always those who drop out during the transitions. In this war, unequivocally, there are a lot fewer cases like these. I think it's because of a sense of the justness of the cause.

"The research is limited, because war is an unexpected event for which controlled studies cannot be conducted in advance, but there is plenty of information and many lessons [to be learned] in retrospect. After the World Trade Center disaster, for example, everyone thought that all of New York would be traumatized. Therapy was offered free to anyone who wanted it, but it was found that most people did not seek it out. It was also found that there may be an initial reaction with multiple symptoms to such a traumatic event, but as time goes by, most people develop ways to cope and can move on. A small group of people developed serious symptoms at the start that then became chronic. And there's a third group that didn't develop symptoms at all at first, but did over time.

"The problem is to distinguish in real time and in advance between these groups. There's no research that can accurately predict during the first three months [after a traumatic event] who will recover spontaneously and who will suffer from PTSD. Because I know, however, that the majority will recover on their own, any intervention I perform must prove that it doesn't do more harm than nonintervention. Accordingly, I will not bring in anyone who doesn't have experience working with this type of population, in order to ensure that they will not cause anyone who has the ability to recover on their own to become chronically ill instead."

But what are the accepted, guiding principles for treatment of trauma?

"The principles of PIE [proximity – keeping the soldier in proximity to the trauma/battle site – immediacy and expectation of recovery] were articulated after World War I, and remain valid today. But the first person in the world who examined their scientific validity was Israeli researcher Zahava Solomon, after the 1982 Lebanon War. Prof. Solomon published a series of studies that showed that a return to some degree of functioning, along with physical proximity to the site of the trauma and immediate intervention, reduced PTSD rates significantly. All modern armies follow this approach today. By the way, [the rate of] PTSD in the Israeli army is lower than in the U.S. Army. That's likely due to the compulsory draft in Israel, which produces troops from a diverse range of communities, as well as the belief in military objectives and social cohesion – and in this war the goal is very clear to everyone."

This war started with an unexpected, mass-traumatic event: the Hamas massacre in the communities abutting the Strip – a war of the few against the many, hostages, the Nova rave. What was the impact of all that?

"We do in fact see more PTSD among those [soldiers] who experienced the trauma of October 7 [on the kibbutzim and at the rave], as compared to combatants involved in the ground operation in Gaza. This can be attributed to the element of surprise, the feeling of helplessness, the fact that many of the soldiers who were wounded [that day] were not combat troops. There's a big difference between an experience like this and knowing that 'I'm a fighter, I'm entering a zone that's under threat, there could be losses, I might be wounded and my friends might be wounded.' It's scary, but you're prepared for the event and feel more in control. But one must take all of these observations with a grain of salt because not enough time has passed [since the war broke out]. At the moment, the soldiers are active and living within a social framework that is sustaining them, for better or worse."

Many of the soldiers who experienced the events of October 7 or were at the Nova festival went on to fight. There are also reservists who are still suffering from PTSD from previous incidents and wars. Isn't that dangerous for their psyche?

"That's a tricky question. I'm looking at functionality. If soldiers continue to function in every way, then that's fine, we don't touch them. If we see a concrete functional breakdown, we will not send them into combat of course. But some are exposed to traumatic events – and could yet develop symptoms – but are meanwhile functioning and want to take part in the fighting, and that's where there's a dilemma."

What is the dilemma?

"These troops are more likely to develop PTSD, because one of its risk factors is earlier exposure to a traumatic incident. So, we didn't compel people like that to fight, although we did allow them to fight and even encouraged it, because people feel meaning and a connection to a mission and want to cope; it imbues them with more strength and makes better recovery possible. But it's difficult to know in advance which of those elements will win out."

Were mistakes made in some instances by sending soldiers previously suffering from PTSD into Gaza?

"We called up hundreds of thousands, and there were a few cases in which we had to discharge people, or in which crises developed due to what was happening."

The element of functionality

There are some soldiers who are afraid to be deployed in Gaza, and others who are afraid to leave home after a furlough. How do you induce someone to risk their life on the battlefield?

"It's a tough decision, and the fear is perfectly natural. It's not rational to go out and take on someone who's shooting at you, but because that must be done, the army trains the soldiers [accordingly]. How is fear overcome? People train in groups, and confidence in their capabilities is built up – by way of the rightness of their path, by their commanders, by way of the organization that sends you into battle for a just reason, and in the notion that if something should happen to you, there will be someone to take care of you. There are always people who are afraid to go into battle, and generally it's their superiors who deal with that."

What is psychologically the most difficult for soldiers?

"The transitions. It's very difficult to return to battle after a home furlough, but when speaking with soldiers who are there, they somehow accept that. And in parallel, when they leave the battlefield for home, that's difficult, too. There are always those who drop out (do not return to combat) during the transitions, and that phenomenon intensifies when the war is protracted. It's something you see in all armies. In this war, unequivocally, there are a lot fewer cases like these [than in other of Israel's wars], and they're mostly handled by commanders. I think it's because of a sense of the justness of the cause, as the [high reserve] draft rates show. But as time passes, there is burnout, and people want to return to their life. They have families, a livelihood."

One of the most highly contentious issues confronting soldiers, parents and the army in general during the Gaza war has been the issue of furloughs. Whereas some units have been able to be in constant touch with their homes, and even occasionally enjoyed some R&R, either at home or under army auspices at sites outside of Gaza – in others, such as the Paratroops, the furlough policy was far more stringent. [The soldiers were only allowed few breaks from combat during a four-month period.] The parents of soldiers in those units raised a hue and a cry among the top brass as well as in the media, claiming that their sons and daughters were suffering psychological damage from their lengthy absence from home.

As the person in charge of the mental well-being of IDF soldiers, what did you think of the decision by some commanders to leave soldiers in Gaza for such a long time at a stretch?

"That's the commander's decision, and there are two considerations involved. One is that the transitions are difficult and are marked by incidents in which people drop out, and the second is that what reduces the rates of PTSD and sustains soldiers in combat is their connection to supportive elements like the family. The question is when I should intervene in the commander's considerations. As long as it's not an issue of mental pathology– and healthy people who don't go back home are not prone to developing a pathology – there is no place for my intervention. There is no research that says what the mental danger is if the parents are seen every two weeks as opposed to once a month.

"Personally, I think we should rely on the soldiers: If they're brave enough to fight the enemy, we can trust that they won't fall apart when they meet their parents and return to battle, but it's not my place to be a substitute for the commander."

But even so, as a professional, can't you take a stand and say: "No more – they're liable to fall apart"?

"If I were certain that psychological damage was being caused, I would intervene, but I can't say that someone who sees or doesn't see home and their parents will develop PTSD. There are considerations here of burnout, motivation, differences in furloughs from brigade to brigade, and within that overall picture we make recommendations to commanders but we don't coerce them."

This is all very hard on the parents, too – some of them find it genuinely difficult to function. Is there not a possibility of taking their difficulties into consideration?

"That's not my mandate, but it's a conscript army and a people's army, and as such there is no alternative but to take into account the parents and their views. That said, the war has to be conducted by the commanders, and war is a difficult psychological experience."

Fear is perfectly natural. It's not rational to go out and take on someone who's shooting at you, but because that must be done, the army trains the soldiers. How is fear overcome? People train in groups, and confidence in their capabilities is built up.

Have you been surprised by this generation of fighters?

"Everyone spoke about a lack of resilience among the 'post-COVID generation' and about problems of interpersonal communication, but we have all been favorably surprised by esprit de corps, the volunteering and the mobilization. Commanders have asked that we supply them with mental health officers and have been adept at making use of them in order to rebuild capability and esprit de corps. It was obvious already in the first week that everyone was dedicated [to the war effort], and they were also able to tell the mental health officers, 'Take a step back, we don't need you anymore.'"

Are there generational differences in mental resilience – between reservists and those serving in the regular army?

"There is no rule of thumb here. The Home Front's mental health officer consulted with me when people had to be tasked with identifying the fallen. He wrestled with the issue of whether to deploy older personnel who would be capable of coping with the sights, or younger soldiers. There is no research literature on this question – you simply have to make a judgment call."

Benchmark event

One thing is not in doubt: This war will be a benchmark in terms of the army's handling of the soldiers' mental health. The numbers strain credulity: As of the first half of this month, over than 1,700 soldiers suffering from stress, shell shock and combat fatigue had been treated by teams of mental health professionals. These treatment teams are manning two R&R-type centers near the Gaza border, and provide several hours or days of treatment for soldiers manifesting combat stress symptoms that have impaired their functioning. Some 85 percent have returned to combat from these centers.

About 1,000 soldiers, however, have required further treatment at a branch of the Home Front Rehabilitation Center, in which experienced mental health officers and psychiatrists treat soldiers suffering from an initial condition known as "acute stress disorder," which requires significant therapeutic intervention so that it doesn't become chronic PTSD. Of these, some 200 soldiers have been discharged from the IDF after being assigned the lowest medical profile of 21 (meaning they are unfit for service). Around 75 percent ultimately returned to service.

In the first month or so after the war broke out, 800 staffers were working at the rehab center and almost 3,500 calls were received on a special mental health hot line set up by the army. But that's a drop in the ocean: Tatsa-Laur says that the majority of the wounded, numbering in the thousands, have developed PTSD symptoms and other psychological problems that will demand therapy and follow-up. In addition, some 30,000 combat troops have met with a mental health officer either during the time they were fighting in Gaza or just before returning home.

In light of these vast numbers, which represent only a fraction of what can be expected, the IDF's Technological and Logistics Directorate decided to dramatically expand the army's existing mental health system and is working to address the needs that have cropped up in the last five months. A new unit it is creating in cooperation with the Medical Corps – under whose auspices Tatsa-Laur's department and other mental health services provided in the army operate – will focus on the realms of combat stress, recovery and rehabilitation. It will have its own insignia, attesting to its independent status.

"Mental health is no longer a matter of a department, but rather of a center that both sets policy and runs specialist clinics," Tatsa-Laur notes. "Personnel who are manning the veteran combat response unit, which deals with all those discharged from regular or reserve service who suffer from PTSD, will surge from 200 to 1,000 and will be deployed in the north, south and center of the country."

In addition, a new unit will be established, to be known as Ta'atsumot, which will cater to any soldiers suffering from psychological problems, including acute or chronic stress disorder, as a result of the current war, whether from combat in Gaza or involvement in battles on October 7 in the adjacent communities. "We need to deal also with populations that were not part of the fighting and did not prepare for it, like all those who worked in Shura, the base where the fallen have been identified."

A new rehabilitative facility was also established at Base 80, located in Pardes Hannah, outside Haifa, which is, says Tatsa-Laur, "a kind of interim, non-hospitalization space for army personnel who have returned mentally scarred from combat and are unable to function in such a capacity again, but whose rehabilitative potential is high. The mental health staff there work with the soldiers until they are fully rehabilitated."

Is the final goal to have these troops return to combat duty?

"No. My goal is exclusively to preserve the health and well-being of the soldier. If the soldiers think that what I'm doing is designed to promote the order of battle and combat, they will lose their confidence in me and I will lose my therapeutic ability."

In addition, a new branch of the Medical Corps is being established whose aim is to enhance the mental resilience of soldiers and officers in the regular army and the reserves, in general. "The staff will deal with issues such as regulating emotions, attention and concentration, providing soldiers with tools to cope with difficult situations and also imparting to commanders so-called soft skills, such as attentiveness, empathy and dealing with situations of distress." The center for the treatment of career personnel and their families will also benefit from increased funding and personnel in its two branches, in the north and south.

What will it do?

"It deals with situations of burnout and prolonged combat, like what's going in the West Bank. It's not PTSD, but other aspects of resilience."

Apropos resilience, the mental health needs of both male and female soldiers are not always related to wartime or to PTSD. Even before the war it was very difficult to get an appointment with a mental health officer.

"That's true, which is why the new mental health center will feature additional personnel who will serve the home front, bases like the Kirya [defense establishment HQ in Tel Aviv] and at Sheba Medical Center. Before the war, we managed to shorten the waiting time for a mental health officer to 14 days for combat troops, but in the home front people still waited three-four months. Now, during the war, people who come from the fighting can see a mental health officer [fairly quickly], after the emergency mobilization of hundreds of them."

Now, with all the new services the army is creating, you'll have to bring in civilian mental health personnel to work full-time – not an easy challenge, because there's a serious shortage of therapists in civilian life, too.

"That is a challenge. The IDF is offering an attractive framework with a mission, interesting work, training and plenty of responsibility, but the job is not an easy one. Some of them will have to serve on bases in the Arava [desert] or the Negev. We will bring in clinical social workers with an undergraduate degree, and train and instruct them in the clinical department of the IDF's school for mental health officers."

Is the bottom line that we are going to see a generation battered by PTSD, as we had after the Yom Kippur War?

"There are different degrees of trauma and that is only one of the phenomena that are emerging. Some people will develop depression, anxiety, or have problems of adjustment. But it's clear there is something big going on here, on a national scale. Since we are in uncharted territory, we can only do our best and attempt to provide a suitable response for everyone, because what we were able to offer up until October 7 is not enough. The IDF is today doing far more than it ever did on the subject of prevention [of psychological problems], such as a providing a week to allow soldiers to process what they've gone through before they return to [civilian] life. And we expect that there will be a rise in the demand for mental health services, in general."

What do you say to reservists who have returned home in recent weeks and are having a tough time going back to routine, to work, to family?

"I wish that as a psychiatrist, I had a magic wand that could make this whole period disappear. But it's important for me to tell them: This event is not one that results in sickness. It's a difficult and powerful event; it might change you, but you will not become ill or disabled, even if it's hard for you to resume routine life. The human mind is built to cope with trauma. From the dawn of history, people have fought and have been wounded – and have been able to resume functioning."

2024-03-23T04:51:18Z dg43tfdfdgfd