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A Cross-Cultural Perspective of PTSD & Resilience

Trauma can happen to any one of us, regardless of our background or where we live in the world. How we address trauma determines whether we have power over it, or it over us.

For Dr. Alana Siegel, a clinical psychologist who specializes in trauma, assisting individuals on their journey to recovery is a life calling. Raised in New York City and educated in New York, Paris, and Israel, Alana brings a cross-cultural perspective to every aspect of her work in the field from her current base in Tel Aviv.

From childhood, Alana was fascinated by the human psyche. In college, she majored in human development and by graduate school she completed a master’s in international affairs followed by her doctorate in clinical psychology. As a postdoctoral research fellow, she studied the effects of post-traumatic stress disorder (PTSD) in military veterans and secondary traumatic stress in their partners under the auspices of world-renowned trauma experts.

Alana has lectured internationally on the topics of PTSD and resilience, and she is currently an instructor at Tel Aviv University. She also runs a private practice in Israel offering an eclectic modality of therapies and trauma-focused techniques to patients from a variety of backgrounds.

Alana is outspoken when it comes to tackling the stigma of mental illness, a serious issue that has had negative consequences in the security community, both in Israel and the U.S. As Alana puts it, “Across societies, if you shut out every person with a mental illness, you’re shutting out a lot of potential.”

Read on to learn about the diverse dynamics of trauma, the types of mindsets that lead to post-traumatic growth, and the interesting differences between the American versus Israeli military landscapes.

* You can view some of the fascinating topics Alana has covered in her research here.

Jessica: What inspired you to pursue a career in psychology, with a particular focus on post-traumatic stress?

Alana: From a young age, I’ve been fascinated by the human psyche: how people process events, how they develop, how they change over a lifespan. It wasn’t until my junior year at Cornell University majoring in human development that I started to focus my studies on trauma.

Trauma is a great equalizer. It doesn’t matter if you’re young, old, rich, poor, or where you live in the world—a traumatic event can happen to anyone. Trauma can be acute or chronic; it can happen in the home or out in the world.

I’ve studied trauma on both the micro and macro levels, which led me after my psychology degree to pursue a master’s in international affairs, a doctorate in clinical psychology, and two postdocs in the field of trauma. One aspect of trauma that particularly interests me is in the area of resilience.

I’m amazed by the strength of the human spirit, how people have the ability to bounce back from adverse circumstances and carve out the lives they want. It’s very meaningful to me as a clinician to help people process intense experiences and thrive.

Jessica: You’ve worked with families in foster care, with survivors of domestic violence, child abuse, and torture. What got you interested more recently in the military?

Alana: I’m based now in Israel, which researchers have called “a living stress laboratory”. Trauma studies in Israel are comprised of a matrix of variables that can’t be found anywhere else in the world. For example, no other country in the world is surrounded by neighboring countries that pose a constant existential threat. As you can imagine, PTSD is something that is heavily studied in Israel, particularly how it affects the military [which includes a national mandatory service].

Dr. Siegel talks at Tel Aviv University about why Israel is the best place in the world for the study of crisis and trauma. [YouTube Link]

At Bar Ilan University and later at Tel Aviv University, I joined teams of academics who study how trauma impacts the family of the soldier, whether that’s the spouse or the children. Remember that Israel also has a high number of civilians affected by war, communities impacted by the trauma of migration, as well as Holocaust survivors—among other groups—so there are many communities in the country who benefit from advanced PTSD treatments.

Jessica: You’re an American who started her training in the U.S. and then completed your post-doctoral studies in Israel. With a foot in both countries, can you discuss some of the differences between the U.S. and Israeli military mental health landscapes?

Alana: While initial studies have found similar rates of PTSD in the U.S. and Israel, the structure of support and military deployment vastly differs. While Israeli soldiers have a lot to contend with, they don’t go on extended deployments like American soldiers.

An American soldier can be deployed multiple times for many months on end, during which time they are separated from their families, their spouses, their homes. They’re separated from their routines, from sex with partners back home, from friendships. This all means time away from healthy schedules and stable mental health support.

Even when stationed in the U.S., American soldiers can be rotated to a different base every few years. That ruptures social support. It takes time to build up friendships, community, and to find physicians or therapists with whom you’re comfortable.

Moving around can cause stress for the rest of the soldier’s family, too. Add to all this the very real problem that the Americans are suffering from a lack of psychological support resources in the military, creating long wait times for soldiers who may be suffering terribly after being wounded or seeing friends die.

Growing up in New York, I didn’t know a single person in my generation who enlisted. So, when it comes to Memorial Day in the U.S., there are many Americans who personally struggle to understand the significant sacrifices that military service members and their families have made for their country.

By contrast, most Israelis serve and have family members and friends who served, too. Their longest deployments last weeks (at most), not months. I think there’s really something to be said for returning home to your partner, eating a delicious meal at your own table, sleeping in your own bed, and staying connected with friends who understand you.

On Memorial Day in Israel, sirens of mourning blast across the country, traffic comes to a complete standstill, citizens are united. Almost everyone in Israel knows someone who was injured or killed in a war. An Israeli soldier knows he’s not alone.

The unique stress that Israelis have to deal with is ongoing war and conflicts since the inception of the state in 1948. Israel has managed thankfully to sign peace treaties with Egypt and Jordan, but the country still contends with the Iranian nuclear threat, the ongoing war in Syria, conflict with the Palestinians in the West Bank and Gaza, and intermittent wars with Lebanon.

It’s a demanding situation, but as a result Israel has a very strong community of mental health experts who are knowledgeable about trauma and how to treat it.

Jessica: Is there anything the U.S. military can learn from the Israelis?

Alana: The military needs to invest in expanding its numbers of mental health clinicians who are knowledgeable about general mental health issues, not just PTSD. For example, there is a high comorbidity between PTSD and depression, anxiety, substance abuse, chronic pain, and suicidality. A case that may present as anxiety could be a result of trauma. The U.S. should be recruiting departments, units, and battalions of mental health professionals that can serve soldiers on a domestic and international basis and can provide support in real time.

At the International Society for Traumatic Stress Studies (c. 2019)

Mental health professionals should also be aware of the effect of trauma on the soldiers’ families. In Israel, we also study secondary traumatic stress among soldiers’ family members. In studies of American veterans, 10-24% of wives have reported post-traumatic stress symptoms and higher levels of distress, anxiety and depression. They’ve reported less intimacy and marital satisfaction, stronger sense of burden, and higher rates of family violence. Problems at home can exacerbate service members’ mental health in a vicious cycle.

Lastly, and I know this might sound like a fantasy, but I think the U.S. military should consider shorter deployments. When deployed, soldiers aren’t getting regular sleep, they’re eating MREs [meal, ready-to-eat], they can lose a sense of time. When you’re living on a base in Iraq or Afghanistan, there’s really nowhere to go to decompress, and the military members may find themselves immersed in total situations. Increasing the time that soldiers are at home and connected to their family and social structures is likely to mitigate negative mental health impacts.

* To learn more about how the U.S. military is working to improve mental health resources, check out the recent interview with Director of Veteran Affairs Kate Kuzminski at the Center for a New American Security (CNAS) titled “The Unseen Obstacles of Military Recruitment.”

Jessica: In some of your past research, you examined the role of patients mastering their own mental health in order to heal more effectively from trauma. Can you explain ideally what that ‘mastery’ looks like?

Alana: Imagine the mindset of a soldier who is suffering from PTSD. Maybe they were exposed to a harsh combat scenario and lost a sense of control over their survival; or, maybe they were sexually assaulted and lost control of their bodies. So, the question is how do you reestablish that sense of control? How do you reframe what happened to them and how they want to live their lives moving forward?

It's complicated to sit with an actual patient and unpack how they see the world. It’s a process to work with the patient on how they want to shift their future outlook, but one of the basic concepts revolves around reestablishing mastery.

‘Mastery’ is defined as the individual's actual or perceived control over significant life circumstances. This feeling of control is incredibly important and something that I talk a lot about with my patients, since the emotional state of mastery is associated with improved psychological wellbeing. In particular, optimism and vitality assist with someone’s ability to cope with hardship.

Another concept that is important to mastery is the external locus of control versus the internal locus of control. To illustrate, with an external locus of control, if you got a good grade on a test, you might say it’s because the teacher likes you or because the stars were aligned that day. If you have an internal locus of control, you would say you got the good grade because you studied hard. So, it’s about this sense of agency over your own abilities and knowing that you’ve made a difference in your life.

For the person who feels very out of control, we work on incremental steps for reinstituting areas of control. Reestablishing control over your own body is important. Over time, these small steps can shift a person’s mindset, reinforcing their sense of agency.

I also focus on the importance of the post-traumatic growth—namely, how the individual can grow as a result of their trauma.

Jessica: Are there any new approaches to PTSD that you've seen in recent years that you find especially promising?

Alana: There are actually four things I’m excited about. First, I’m very interested in EMDR (eye movement desensitization and reprocessing) therapy. It involves moving your eyes in a specific way while processing traumatic memories; the treatment is administered in a limited time period, unlike psychodynamic psychoanalysis which can take place over years.

Second, I’m interested in MAPS (Multidisciplinary Association for Psychedelic Studies). The program uses psychedelics in controlled therapeutic settings. They administer very set and finite doses of MDMA to patients who then lie on a bed in a therapy session for eight hours with two different therapists. People who’ve experienced it have described it like having door after door opened, and they’re able to access memories that have been sealed away for a very long time. It’s still a new therapy, but it’s showing promise.

Presenting at the European Association for Behavioural and Cognitive Therapies (EABCT) International Conference in Jerusalem

The third one is virtual reality (VR), and that is something the U.S. armed forces is currently investing a lot of money in and is accessible across geographic locations. It’s used for training, such as preparing soldiers to walk down a street in Iraq and see a car bomb go off. For PTSD, VR allows soldiers to revisit a traumatic incident, providing repeated exposure in a real time, very controlled way.

The fourth one is therapy that takes place virtually, rather than in person. It’s opened an entirely new world for therapy, making it more accessible to soldiers. Someone on an army base in the middle of nowhere in Montana doesn’t have to drive over an hour to see a therapist when he can access someone in Massachusetts over the Internet.

You can join a support group as well over the Internet with others who are struggling with PTSD or addiction or sexual assault. If you’re a soldier who is particularly anxious about stigma and wants to avoid seeking treatment on base, you can use the Internet to access a private therapist.

Jessica: In previous publications, you’ve mentioned the general societal stigma attached to mental illness. (Obviously this stigma is even more magnified in the security field.) What do you believe is the root cause driving this stigma?

Alana: I think there is a deep-seated fear or desire to distance oneself from being labeled as “damaged” or “crazy.” Societies all over the world harbor stereotypes, prejudice, and discrimination against the mentally ill. There was an article in The New York Times in 2015 that profiled countries in Africa where people with mental illness were chained and hidden away. All over the world there are people who hide away relatives with mental health issues out of fear that it will stigmatize the entire family.

This societal stigma can also result in self-stigma, in which the individual internalizes the negative societal stereotypes. It can destroy the individual’s self-esteem, making one believe that he or she isn’t capable of being competent or a high achiever if they’re struggling with a mental health issue. The stigma of mental illness can devastate people both personally and professionally.

An example of someone speaking out specifically against this phenomenon is Dr. Patrick Corrigan. He’s a successful professor of psychology and a sufferer of bipolar disorder. He not only speaks out against stigma based on his own experience and conducts research in this area, but is an example of a thriving individual in the face of mental health challenges.

* To learn more about Dr. Patrick Corrigan’s work, check out this recent interview titled “Confronting the Stigma of Mental Illness.”

It honestly infuriates me how society treats the mentally ill. There’s no stigma around having cancer or breaking a leg. In those cases, your community or workplace is likely to rally around you, to bring you meals, to offer emotional support. When it comes to mental illness, people prefer to distance themselves from the sufferer instead, which is unfair.

More people are starting to speak out, but it will take significant effort to change perceptions. Across societies, if you shut out every person with a mental illness, you’re shutting out a lot of potential.

* * *

About Jessica Lauren Walton: Jessica is a communications strategist, video producer, and writer in the U.S. defense sector. She has written articles on a range of security and mental health topics and conducted interviews with military leadership, CIA officers, law enforcement, psychologists, filmmakers, and more. Jessica recently completed her memoir about her experience as an American woman struggling with mental illness while trying to get into Israeli intelligence.

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